Healthcare Provider Details

I. General information

NPI: 1033101340
Provider Name (Legal Business Name): BRENDA FAYE VELLANCE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2843 ALTERNATE 19
PALM HARBOR FL
34683
US

IV. Provider business mailing address

227 DUNBRIDGE DR
PALM HARBOR FL
34684-3704
US

V. Phone/Fax

Practice location:
  • Phone: 727-772-0038
  • Fax: 727-787-2384
Mailing address:
  • Phone: 727-772-0038
  • Fax: 727-787-2384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberFLMH3808
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: