Healthcare Provider Details

I. General information

NPI: 1750751897
Provider Name (Legal Business Name): BRENDA MCDANIEL MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N 3RD ST
MONROE LA
71201-5844
US

IV. Provider business mailing address

908 N 3RD ST
MONROE LA
71201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-8748
  • Fax:
Mailing address:
  • Phone: 318-325-8748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7281
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC6110
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: