Provider Demographics
NPI:1902028582
Name:KNIPPENBERG, BRENDA (COTAL,CWT,SLPA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KNIPPENBERG
Suffix:
Gender:F
Credentials:COTAL,CWT,SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S ACACIA APT 1069
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2946
Mailing Address - Country:US
Mailing Address - Phone:480-704-3550
Mailing Address - Fax:
Practice Address - Street 1:450 S ACACIA APT 1069
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-2946
Practice Address - Country:US
Practice Address - Phone:480-704-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2892224Z00000X
AZ2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Not Answered2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant