Healthcare Provider Details

I. General information

NPI: 1518755651
Provider Name (Legal Business Name): DAVID BRINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 W WESTERN AVE
SOUTH BEND IN
46619-2622
US

IV. Provider business mailing address

58450 WINDSOR AVE
SOUTH BEND IN
46619-9481
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-1524
  • Fax:
Mailing address:
  • Phone: 574-876-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number33012250A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: