Provider Demographics
NPI:1548042278
Name:MONGE, BRENDA JUDITH
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JUDITH
Last Name:MONGE
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:PO BOX 371112
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91337-1112
Mailing Address - Country:US
Mailing Address - Phone:818-903-5811
Mailing Address - Fax:
Practice Address - Street 1:1530 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3023
Practice Address - Country:US
Practice Address - Phone:213-747-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2024-11-04
Deactivation Date:2023-10-31
Deactivation Code:
Reactivation Date:2023-11-09
Provider Licenses
StateLicense IDTaxonomies
CA143576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist