Provider Demographics
NPI:1174764542
Name:WOOTEN, BRENDA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MICHELLE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 NW 156TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33054-6915
Mailing Address - Country:US
Mailing Address - Phone:305-621-2226
Mailing Address - Fax:
Practice Address - Street 1:2445 NW 156TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33054-6915
Practice Address - Country:US
Practice Address - Phone:305-621-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency