Provider Demographics
NPI:1801018502
Name:SMALL, BRENDA B (RD , LD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:B
Last Name:SMALL
Suffix:
Gender:F
Credentials:RD , LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 FAIRMONT CT
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1314
Mailing Address - Country:US
Mailing Address - Phone:936-539-9048
Mailing Address - Fax:936-539-9343
Practice Address - Street 1:521 INTERSTATE 45 S STE 12
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-5651
Practice Address - Country:US
Practice Address - Phone:936-291-0900
Practice Address - Fax:936-291-0955
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXDT00499133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered