Provider Demographics
NPI:1790792091
Name:WIENS, BRENDA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:WIENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ANN
Other - Last Name:WIENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-0294
Mailing Address - Fax:352-265-0096
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0294
Practice Address - Fax:352-265-0096
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7067103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252111300Medicaid
74428ZMedicare PIN
FL252111300Medicaid