Basic Information
| Provider Information | |||||||||
| NPI: | 1891055034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLEMAN | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MT-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CRATER LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416222186 | ||||||||
| FaxNumber: | 5417709212 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 CRATER LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416222186 | ||||||||
| FaxNumber: | 5417709212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225A00000X | MT-T-10179874 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist |
No ID Information.