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General NPI Number Information
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NPI Number | 1447537766
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Entity Type | Individual
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Provider Name | BEAU CHARLES BRENDLEY PSY D
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Gender | Male
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Dates
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Enumeration Date | 11/15/2011
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Last Update Date | 09/25/2018
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Provider Practice Location Address
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Address Line | 255 S 17TH ST STE 1010
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City | PHILADELPHIA
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State | PA
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Zip | 19103-6210
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Country | US
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Telephone | 672-319-5882
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Fax |
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Provider Business Mailing Address
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Address Line | 815 S 2ND ST
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City | PHILADELPHIA
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State | PA
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Zip | 19147-3415
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Country | US
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Telephone | 267-231-9588
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC006129
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PS018603
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License Number State | PA
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