Provider Demographics
NPI:1548099963
Name:HARTUNG, BRENDA ILIANA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ILIANA
Last Name:HARTUNG
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 1:4808 W EL CAMINITO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-6415
Mailing Address - Country:US
Mailing Address - Phone:714-955-1354
Mailing Address - Fax:
Practice Address - Street 1:2400 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3106
Practice Address - Country:US
Practice Address - Phone:602-955-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist