Provider Demographics
NPI:1306066709
Name:CHAN, BRENDA (SPEECH THERAPIST)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 HENDERSON AVE.
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1540
Mailing Address - Country:US
Mailing Address - Phone:765-497-0655
Mailing Address - Fax:765-497-0655
Practice Address - Street 1:3401 SOLDIERS HOME RD.
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906
Practice Address - Country:US
Practice Address - Phone:765-463-1541
Practice Address - Fax:765-497-0687
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001474A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000243264OtherANTHEM PIN #