Provider Demographics
NPI:1679553507
Name:MCGAVOCK, BRENDA (PH,D)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:MCGAVOCK
Suffix:
Gender:F
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 FORUM BLVD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5450
Mailing Address - Country:US
Mailing Address - Phone:573-446-4039
Mailing Address - Fax:573-446-4123
Practice Address - Street 1:2716 FORUM BLVD
Practice Address - Street 2:SUITE 2B
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5450
Practice Address - Country:US
Practice Address - Phone:573-446-4039
Practice Address - Fax:573-446-4123
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist