Provider Demographics
NPI:1720118995
Name:WICKS, BRENDA IVELISS (LMFT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:IVELISS
Last Name:WICKS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:IVELISS
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4000 W METROPOLITAN DR STE 401
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3506
Mailing Address - Country:US
Mailing Address - Phone:714-936-4978
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 401
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3506
Practice Address - Country:US
Practice Address - Phone:714-936-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist