=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902211949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. BRENDA SIROIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2014
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1853 VICTORIA AVE
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-3428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-273-0270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12059 RICHARDS AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33981-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-225-7672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------