Healthcare Provider Details

I. General information

NPI: 1538773239
Provider Name (Legal Business Name): BRENDA EILEEN HAGA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12276 SAN JOSE BLVD
JACKSONVILLE FL
32223-8628
US

IV. Provider business mailing address

83 W 4TH ST
ATLANTIC BEACH FL
32233-3309
US

V. Phone/Fax

Practice location:
  • Phone: 904-886-3228
  • Fax:
Mailing address:
  • Phone: 516-317-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: