Healthcare Provider Details

I. General information

NPI: 1023594389
Provider Name (Legal Business Name): BRENDAH NAMWAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SEMANDS ST
CONROE TX
77301-1867
US

IV. Provider business mailing address

12502 SEATTLE SLEW DR APT 1422
HOUSTON TX
77065-4587
US

V. Phone/Fax

Practice location:
  • Phone: 936-756-5598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number326622
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: