MEDICARE: MS. BRENDA KRISTINE HIEMSTRA MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC24467	CA

General Provider Information

NPI Number	:	1518077874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA KRISTINE HIEMSTRA MFT

Provider Business Mailing Address
First Line	:	2891 JUNIPER AVE
Second Line	:
City	:	MORRO BAY
State	:	CA
Zip	:	93442-1446
Country	:	US
Telephone Number	:	805-546-0322
Fax Number	:

Provider Business Practice Location Address
First Line	:	1264 HIGUERA ST
Second Line	:	SUITE 210
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-3124
Country	:	US
Telephone Number	:	805-546-0322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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