Healthcare Provider Details

I. General information

NPI: 1982637583
Provider Name (Legal Business Name): BRENDA-LEE WILDER DUARTE LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 GAMBLE AVE
MARYVILLE TN
37801-4943
US

IV. Provider business mailing address

294 GAMBLE AVE
MARYVILLE TN
37801-4943
US

V. Phone/Fax

Practice location:
  • Phone: 865-981-7400
  • Fax:
Mailing address:
  • Phone: 865-981-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0000000686
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: