Provider Demographics
NPI:1669744322
Name:CENTENO, BRENDA P (PT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:P
Last Name:CENTENO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1738 SPLIT FORK DR
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2767
Mailing Address - Country:US
Mailing Address - Phone:727-488-1856
Mailing Address - Fax:813-412-1693
Practice Address - Street 1:1738 SPLIT FORK DR
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-2767
Practice Address - Country:US
Practice Address - Phone:727-488-1856
Practice Address - Fax:813-412-1693
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886401200Medicaid