Healthcare Provider Details

I. General information

NPI: 1902136690
Provider Name (Legal Business Name): MS. CAROLYN BRENNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2010
Last Update Date: 01/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11132 EDGEBROOK LN
INDIAN HEAD PARK IL
60525-6974
US

IV. Provider business mailing address

11132 EDGEBROOK LN
INDIAN HEAD PARK IL
60525-6974
US

V. Phone/Fax

Practice location:
  • Phone: 708-246-3355
  • Fax:
Mailing address:
  • Phone: 708-246-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149003642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: