Provider Demographics
NPI:1063902641
Name:REDONDO, BRIAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:REDONDO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 NURSERY DR
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-3114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 FAIRTON MILLVILLE RD
Practice Address - Street 2:
Practice Address - City:FAIRTON
Practice Address - State:NJ
Practice Address - Zip Code:08320-2000
Practice Address - Country:US
Practice Address - Phone:856-453-4078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7595-PY-PR103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical