Provider Demographics
NPI:1689895146
Name:WILSON, BRENDA MARIE (LMHC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10526 OLD GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-2604
Mailing Address - Country:US
Mailing Address - Phone:813-857-4154
Mailing Address - Fax:
Practice Address - Street 1:MANATEE SERVICE CENTER
Practice Address - Street 2:600 301 BLVD - SUITE 144
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205
Practice Address - Country:US
Practice Address - Phone:941-741-2981
Practice Address - Fax:941-741-2981
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 6766101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health