Healthcare Provider Details

I. General information

NPI: 1538701750
Provider Name (Legal Business Name): LAURA A BRENNAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MAIN ST
BOWDOINHAM ME
04008-4420
US

IV. Provider business mailing address

35 MAIN ST
BOWDOINHAM ME
04008-4420
US

V. Phone/Fax

Practice location:
  • Phone: 617-765-1228
  • Fax:
Mailing address:
  • Phone: 617-765-1228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11177
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01801
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS2389
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11177
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: