Healthcare Provider Details

I. General information

NPI: 1538506449
Provider Name (Legal Business Name): BRENT PHILLIP BRENDLE M.S. L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 MAIN ST
SOUTHAMPTON NJ
08088-8869
US

IV. Provider business mailing address

PO BOX 2383
SOUTHAMPTON NJ
08088-2383
US

V. Phone/Fax

Practice location:
  • Phone: 609-755-5680
  • Fax:
Mailing address:
  • Phone: 609-755-5680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00389500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: