Provider Demographics
NPI:1679974851
Name:BRENT, ANDREA (MA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BRENT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24330 JOHN R RD # 231
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1112
Mailing Address - Country:US
Mailing Address - Phone:248-793-1501
Mailing Address - Fax:
Practice Address - Street 1:26545 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-793-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016808103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical