Provider Demographics
NPI:1447371075
Name:MACK, BRENDA KAY (MFT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:KAY
Last Name:MACK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 BROADWAY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1500
Mailing Address - Country:US
Mailing Address - Phone:619-546-8012
Mailing Address - Fax:619-546-8012
Practice Address - Street 1:7227 BROADWAY
Practice Address - Street 2:SUITE 302
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1500
Practice Address - Country:US
Practice Address - Phone:619-546-8012
Practice Address - Fax:619-546-8012
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC40160OtherLICENSE