Provider Demographics
NPI:1801177647
Name:BRENEM, MELLESSA K (CI)
Entity type:Individual
Prefix:
First Name:MELLESSA
Middle Name:K
Last Name:BRENEM
Suffix:
Gender:F
Credentials:CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-4803
Mailing Address - Country:US
Mailing Address - Phone:432-570-3333
Mailing Address - Fax:
Practice Address - Street 1:1012 W MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-3341
Practice Address - Country:US
Practice Address - Phone:432-580-2624
Practice Address - Fax:432-580-2609
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8987101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)