Provider Demographics
NPI:1861617136
Name:FARSIDE, BRENDA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:FARSIDE
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 1:11 CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-3101
Mailing Address - Country:US
Mailing Address - Phone:302-438-2796
Mailing Address - Fax:
Practice Address - Street 1:62 ROCKFORD RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1047
Practice Address - Country:US
Practice Address - Phone:302-438-2796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00006121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE200821LSWOtherBCBS PROVIDER #