Provider Demographics
NPI:1881259323
Name:BACON, BRENDALIN A (MS MENTAL HEALTH)
Entity type:Individual
Prefix:MS
First Name:BRENDALIN
Middle Name:A
Last Name:BACON
Suffix:
Gender:F
Credentials:MS MENTAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4713 EL NUEVA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-1035
Mailing Address - Country:US
Mailing Address - Phone:407-256-3718
Mailing Address - Fax:
Practice Address - Street 1:4713 EL NUEVA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946-1035
Practice Address - Country:US
Practice Address - Phone:407-256-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18275101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health