Provider Demographics
NPI:1740772979
Name:SANTILLAN, BRENDA ALICIA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ALICIA
Last Name:SANTILLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8212 AGNES AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-1511
Mailing Address - Country:US
Mailing Address - Phone:818-675-1370
Mailing Address - Fax:
Practice Address - Street 1:7038 OWENSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3198
Practice Address - Country:US
Practice Address - Phone:818-898-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113696101YM0800X
390200000X
CA129832106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program