Provider Demographics
NPI:1730689365
Name:BRINK, INDA LUCILLE (LMFT)
Entity type:Individual
Prefix:
First Name:INDA
Middle Name:LUCILLE
Last Name:BRINK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 S BASCOM AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2600
Mailing Address - Country:US
Mailing Address - Phone:408-351-1044
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE STE 115
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2600
Practice Address - Country:US
Practice Address - Phone:408-351-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35276106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist