Provider Demographics
NPI:1528733045
Name:ALMODOVAR, BRENDA LESE
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LESE
Last Name:ALMODOVAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 TIFFANY BLVD APT 250
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2441
Mailing Address - Country:US
Mailing Address - Phone:973-851-8519
Mailing Address - Fax:
Practice Address - Street 1:90 TIFFANY BLVD APT 250
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2441
Practice Address - Country:US
Practice Address - Phone:973-851-8519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6045531041S0200X
NJ44SC055212001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool