Provider Demographics
NPI:1750818340
Name:TAMAYO, BRENDEN RAY
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:RAY
Last Name:TAMAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 TURF FARM WAY STE 1-153
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-5587
Mailing Address - Country:US
Mailing Address - Phone:801-935-5796
Mailing Address - Fax:
Practice Address - Street 1:220 W GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2835
Practice Address - Country:US
Practice Address - Phone:208-960-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-17-7295-60735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician