Provider Demographics
NPI:1942636584
Name:ROCKWELL, BRENDA C (MA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:C
Last Name:ROCKWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:C
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1423 HARNDEN RD W
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-7415
Mailing Address - Country:US
Mailing Address - Phone:386-256-6129
Mailing Address - Fax:
Practice Address - Street 1:3930 S NOVA RD STE 307
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9293
Practice Address - Country:US
Practice Address - Phone:386-866-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-14
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020114000Medicaid