Healthcare Provider Details

I. General information

NPI: 1457651689
Provider Name (Legal Business Name): KENNETH JOHN BRENIMAN LCSW, RYT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 JEFFERSON ST TOWNHOUSE 9
OAKLAND CA
94612-1402
US

IV. Provider business mailing address

1511 JEFFERSON ST TOWNHOUSE 9
OAKLAND CA
94612-1402
US

V. Phone/Fax

Practice location:
  • Phone: 510-388-2884
  • Fax:
Mailing address:
  • Phone: 510-388-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22958
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number25705 YOGA ALLIANCE
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: