Provider Demographics
NPI:1831184639
Name:YODER, BRENT E (LCSW)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:YODER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11724 ALTOONA DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-8357
Mailing Address - Country:US
Mailing Address - Phone:619-447-7917
Mailing Address - Fax:619-447-0921
Practice Address - Street 1:291 E LEXINGTON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4536
Practice Address - Country:US
Practice Address - Phone:619-447-7917
Practice Address - Fax:619-447-0921
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS93051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942432Medicaid
CASW9305Medicare ID - Type Unspecified