Provider Demographics
NPI:1386400372
Name:LEWIS, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 KYLE WOOD LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4850
Mailing Address - Country:US
Mailing Address - Phone:863-619-2809
Mailing Address - Fax:
Practice Address - Street 1:1124 KYLE WOOD LN
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4850
Practice Address - Country:US
Practice Address - Phone:863-619-2809
Practice Address - Fax:863-644-9590
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1067255106S00000X
FL0-25-15918106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician