Provider Demographics
NPI:1366048449
Name:MOORE, BRENDEN LEE
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:LEE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4046
Mailing Address - Country:US
Mailing Address - Phone:321-413-3366
Mailing Address - Fax:321-306-2880
Practice Address - Street 1:1912 DAIRY RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4046
Practice Address - Country:US
Practice Address - Phone:321-413-3366
Practice Address - Fax:321-306-2880
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140736106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician