Provider Demographics
NPI:1669627162
Name:KING, BRENDA (MS)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 N TEUTONIA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6754
Mailing Address - Country:US
Mailing Address - Phone:414-334-3063
Mailing Address - Fax:
Practice Address - Street 1:4261 N TEUTONIA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6754
Practice Address - Country:US
Practice Address - Phone:414-334-3063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11284101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11284OtherLICENSE