Healthcare Provider Details

I. General information

NPI: 1093982118
Provider Name (Legal Business Name): BRENDA L TICKNOR LIMHP, LMHC, SADC, L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 09/29/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N JEFFERSON AVE
SPRINGFIELD MO
65806-1110
US

IV. Provider business mailing address

405 N JEFFERSON AVE
SPRINGFIELD MO
65806-1110
US

V. Phone/Fax

Practice location:
  • Phone: 402-687-6449
  • Fax:
Mailing address:
  • Phone: 402-687-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2098
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number814
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4316
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1543
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9295
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: