Provider Demographics
NPI:1063420644
Name:VACTOR, BRENDA (LCSW, PIP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:VACTOR
Suffix:
Gender:F
Credentials:LCSW, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 MEMORIAL PKWY SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5393
Mailing Address - Country:US
Mailing Address - Phone:256-882-2003
Mailing Address - Fax:256-705-4630
Practice Address - Street 1:3007 MEMORIAL PKWY SW # SX
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5393
Practice Address - Country:US
Practice Address - Phone:256-882-2003
Practice Address - Fax:256-705-4630
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AL1692C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1063420644OtherALLKIDS
AL1063420644OtherMEDICARE
AL1063420644OtherBLUE CROSS BLUE SHIELD
AL1063420644OtherEPS- EXTENDED PSYCHIATRIC SERVICES
AL1063420644OtherTRICARE
AL1063420644OtherBLUE ADVANTAGE
AL1063420644OtherMEDICAID (CROSSOVER)