Provider Demographics
NPI:1851012199
Name:NEIDEFFER, BRENT EUGENE (MSW)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:EUGENE
Last Name:NEIDEFFER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12922 N OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3350
Mailing Address - Country:US
Mailing Address - Phone:813-972-2000
Mailing Address - Fax:813-631-3380
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD # A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:813-631-3380
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical