MEDICARE: BRENDEN JESUS RAIZOLA LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC12221	OK

General Provider Information

NPI Number	:	1811738222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDEN JESUS RAIZOLA LPCC

Provider Business Mailing Address
First Line	:	9733 SW 24TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73128-1900
Country	:	US
Telephone Number	:	580-650-8249
Fax Number	:

Provider Business Practice Location Address
First Line	:	10401 GREENBRIAR PKWY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7662
Country	:	US
Telephone Number	:	580-650-8249
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	02/11/2026

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