Provider Demographics
NPI:1245192301
Name:MOCTEZUMA MANZO, BRENDA (BT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MOCTEZUMA MANZO
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 WILD DUCK CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2609
Mailing Address - Country:US
Mailing Address - Phone:704-751-7763
Mailing Address - Fax:
Practice Address - Street 1:7903 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-9720
Practice Address - Country:US
Practice Address - Phone:704-440-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician