Provider Demographics
NPI:1689722274
Name:BRONDYKE, TRYNETTE A (RNLMSW)
Entity Type:Individual
Prefix:
First Name:TRYNETTE
Middle Name:A
Last Name:BRONDYKE
Suffix:
Gender:F
Credentials:RNLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2588
Mailing Address - Country:US
Mailing Address - Phone:269-373-8878
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:2961 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-399-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M09390Medicare ID - Type Unspecified