Provider Demographics
NPI:1851368195
Name:WETZEL, BRENDA (LCSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WETZEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54410 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1632
Mailing Address - Country:US
Mailing Address - Phone:574-273-9514
Mailing Address - Fax:
Practice Address - Street 1:17903 S.R. 23
Practice Address - Street 2:SUITE #3
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-243-7730
Practice Address - Fax:574-243-7735
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2010-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340013421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN237580WMedicare ID - Type Unspecified
S20413Medicare UPIN