Healthcare Provider Details

I. General information

NPI: 1104972546
Provider Name (Legal Business Name): MS. BRENDA MERYL SIEGEL BERCUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 GREENWICH ST
SAN FRANCISCO CA
94123-3405
US

IV. Provider business mailing address

15 CORTE DEL CORONADO
LARKSPUR CA
94939-1503
US

V. Phone/Fax

Practice location:
  • Phone: 415-346-8640
  • Fax:
Mailing address:
  • Phone: 415-927-4839
  • Fax: 415-927-4839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number338251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: