Healthcare Provider Details

I. General information

NPI: 1144717828
Provider Name (Legal Business Name): BRENDA OSORIO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

IV. Provider business mailing address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8708
  • Fax: 310-829-8455
Mailing address:
  • Phone: 310-829-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number33086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY33086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: