Healthcare Provider Details

I. General information

NPI: 1285163378
Provider Name (Legal Business Name): KOMILA BRENNAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9810 PATUXENT WOODS DR
COLUMBIA MD
21046-1595
US

IV. Provider business mailing address

605 W 36TH ST
BALTIMORE MD
21211-2515
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-9200
  • Fax:
Mailing address:
  • Phone: 334-306-7219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number06048
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: