Provider Demographics
NPI:1447537766
Name:BRENDLEY, BEAU CHARLES (PSY D)
Entity type:Individual
Prefix:MR
First Name:BEAU
Middle Name:CHARLES
Last Name:BRENDLEY
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3415
Mailing Address - Country:US
Mailing Address - Phone:267-231-9588
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST STE 1010
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6210
Practice Address - Country:US
Practice Address - Phone:672-319-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006129101YP2500X
PAPS018603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional