Healthcare Provider Details

I. General information

NPI: 1063137917
Provider Name (Legal Business Name): JENAE BRENDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 RADIO STATION RD
LA PLATA MD
20646-3337
US

IV. Provider business mailing address

1062 KELLINGER DR
BADEN PA
15005-1010
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-7432
  • Fax:
Mailing address:
  • Phone: 724-759-5020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number31615609
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: