Healthcare Provider Details

I. General information

NPI: 1740609312
Provider Name (Legal Business Name): MRS. BRENDA JOYCE SYPOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 PERSIMMON DR
ST CHARLES IL
60174-1386
US

IV. Provider business mailing address

730 PERSIMMON DR
ST CHARLES IL
60174-1386
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-2145
  • Fax: 630-377-5211
Mailing address:
  • Phone: 630-779-2145
  • Fax: 630-377-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149.008834
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: