Provider Demographics
NPI:1982373460
Name:STREET, BRENDA MARIE
Entity Type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:MARIE
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 HAYCASTLE CT
Mailing Address - Street 2:
Mailing Address - City:NEWMAN
Mailing Address - State:CA
Mailing Address - Zip Code:95360-9541
Mailing Address - Country:US
Mailing Address - Phone:209-695-8421
Mailing Address - Fax:
Practice Address - Street 1:941 HAYCASTLE CT
Practice Address - Street 2:
Practice Address - City:NEWMAN
Practice Address - State:CA
Practice Address - Zip Code:95360-9541
Practice Address - Country:US
Practice Address - Phone:209-695-8421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32772247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other