Provider Demographics
NPI:1649678319
Name:BRDA, DIANA (MA, LLP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BRDA
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8243 MILBURN ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1767
Mailing Address - Country:US
Mailing Address - Phone:734-751-2543
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST STE 280
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1060
Practice Address - Country:US
Practice Address - Phone:734-751-2543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361001520103T00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other