Provider Demographics
NPI:1972117489
Name:PITA, BRENDA GUADALUPE (RBT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:GUADALUPE
Last Name:PITA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-7313
Mailing Address - Country:US
Mailing Address - Phone:901-618-9277
Mailing Address - Fax:
Practice Address - Street 1:1236 CHERRYDALE CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-8104
Practice Address - Country:US
Practice Address - Phone:901-830-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-19-94135106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician