Healthcare Provider Details

I. General information

NPI: 1063771269
Provider Name (Legal Business Name): LAURA A BRENKE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

IV. Provider business mailing address

1640 ROCKPORT RD
HAMPSHIRE IL
60140-9062
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax:
Mailing address:
  • Phone: 224-520-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.008142
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: