Provider Demographics
NPI:1932633302
Name:BRENDA HEIDRICH
Entity Type:Organization
Organization Name:BRENDA HEIDRICH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIRICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-748-8393
Mailing Address - Street 1:11387 THURSTON PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2428
Mailing Address - Country:US
Mailing Address - Phone:310-748-8393
Mailing Address - Fax:
Practice Address - Street 1:270 26TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2543
Practice Address - Country:US
Practice Address - Phone:319-748-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty