Provider Demographics
NPI:1669949384
Name:MATHER, BRENDA JEAN
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:MATHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612-8819
Mailing Address - Country:US
Mailing Address - Phone:989-435-3660
Mailing Address - Fax:
Practice Address - Street 1:655 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-2215
Practice Address - Country:US
Practice Address - Phone:989-426-9295
Practice Address - Fax:989-426-2251
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4076219101Y00000X
MI6401014036101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor