Healthcare Provider Details

I. General information

NPI: 1548327422
Provider Name (Legal Business Name): GREGORY P BRENNEISEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DRIVE
MANTENO IL
60950
US

IV. Provider business mailing address

1 VETERANS DRIVE BLDG A2M
MANTENO IL
60950
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-6581
  • Fax: 815-468-7001
Mailing address:
  • Phone: 217-222-9487
  • Fax: 217-222-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: