Provider Demographics
NPI:1538773239
Name:HAGA, BRENDA EILEEN (MS)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:EILEEN
Last Name:HAGA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3309
Mailing Address - Country:US
Mailing Address - Phone:516-317-3600
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225400000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner