Provider Demographics
NPI:1871930123
Name:BRADYMIRE, RENA L (LPC)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:L
Last Name:BRADYMIRE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:RENA
Other - Middle Name:LORINNE
Other - Last Name:MINTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2201 N GOVERNMENT WAY STE K
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3658
Mailing Address - Country:US
Mailing Address - Phone:208-664-0552
Mailing Address - Fax:209-262-9698
Practice Address - Street 1:2201 N GOVERNMENT WAY STE K
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3658
Practice Address - Country:US
Practice Address - Phone:208-664-0552
Practice Address - Fax:209-262-9698
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60074397101YM0800X
IDLPC-3454101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health