Healthcare Provider Details

I. General information

NPI: 1275046385
Provider Name (Legal Business Name): BRENDA LILIANA GANDARA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15615 ALTON PKWY STE 230
IRVINE CA
92618-7306
US

IV. Provider business mailing address

15615 ALTON PKWY STE 230
IRVINE CA
92618-7306
US

V. Phone/Fax

Practice location:
  • Phone: 949-528-6300
  • Fax:
Mailing address:
  • Phone: 949-528-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: