Provider Demographics
NPI:1720034440
Name:DEERE, BRENDA RUNYON (MA, LPA, CPLC, CPWLC)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:RUNYON
Last Name:DEERE
Suffix:
Gender:F
Credentials:MA, LPA, CPLC, CPWLC
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:ELISE
Other - Last Name:DEERE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, CPLC, CPWLC
Mailing Address - Street 1:14466 REFLECTION LAKES DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1806
Mailing Address - Country:US
Mailing Address - Phone:239-791-8679
Mailing Address - Fax:
Practice Address - Street 1:14466 REFLECTION LAKES DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1806
Practice Address - Country:US
Practice Address - Phone:239-791-8679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2251OtherPSYCHOLOGY LICENSE NUMBER
NC6107167Medicaid