Provider Demographics
NPI:1265895411
Name:WOUDENBERG, BRENDA SUE (BEHAVIORAL TECH)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:WOUDENBERG
Suffix:
Gender:F
Credentials:BEHAVIORAL TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 TUSTIN AVE # C151
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4729
Mailing Address - Country:US
Mailing Address - Phone:616-745-2095
Mailing Address - Fax:
Practice Address - Street 1:7700 IRVINE CENTER DR STE 220
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3012
Practice Address - Country:US
Practice Address - Phone:616-745-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213075224Z00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant