Healthcare Provider Details

I. General information

NPI: 1568625895
Provider Name (Legal Business Name): BRENDA KAY HAVELLANA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 75TH DR NE
MARYSVILLE WA
98270-6804
US

IV. Provider business mailing address

3224 75TH DR NE
MARYSVILLE WA
98270-6804
US

V. Phone/Fax

Practice location:
  • Phone: 425-387-6972
  • Fax:
Mailing address:
  • Phone: 425-387-6972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY60014648
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60014648
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPY60014648
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: