Provider Demographics
NPI:1790309151
Name:WARD, BRENDA (INC)
Entity Type:Individual
Prefix:PROF
First Name:BRENDA
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:INC
Other - Prefix:PROF
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:HEARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:QMHP
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:COBBS CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:23035-0031
Mailing Address - Country:US
Mailing Address - Phone:757-810-2056
Mailing Address - Fax:
Practice Address - Street 1:6253 BUCKLEY HALL RD
Practice Address - Street 2:
Practice Address - City:COBBS CREEK
Practice Address - State:VA
Practice Address - Zip Code:23035-2131
Practice Address - Country:US
Practice Address - Phone:757-810-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11056662Medicaid