Provider Demographics
NPI:1881123917
Name:HEIDRICH, BRENDA (PHD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HEIDRICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11387 THURSTON PLACE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:1310-748-8393
Mailing Address - Fax:
Practice Address - Street 1:270 , 26 TH STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402
Practice Address - Country:US
Practice Address - Phone:310-748-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical