Provider Demographics
NPI:1659890200
Name:HART BAILEY, BRENDA LEE (MENTAL HEALTH WORKER)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:HART BAILEY
Suffix:
Gender:F
Credentials:MENTAL HEALTH WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 CRAVENS AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-3203
Mailing Address - Country:US
Mailing Address - Phone:310-328-0588
Mailing Address - Fax:310-328-9636
Practice Address - Street 1:1617 CRAVENS AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-3203
Practice Address - Country:US
Practice Address - Phone:310-328-0855
Practice Address - Fax:310-328-9636
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT117149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA74566OtherBBS