Healthcare Provider Details

I. General information

NPI: 1508102443
Provider Name (Legal Business Name): BRENDA KLEPACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 N. MERIDIAN # 403522
MIAMIA BEACH FL
33140
US

IV. Provider business mailing address

PO BOX 403522
MIAMI BEACH FL
33140
US

V. Phone/Fax

Practice location:
  • Phone: 786-277-6398
  • Fax:
Mailing address:
  • Phone: 786-277-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH2530
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT1386
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: