Healthcare Provider Details

I. General information

NPI: 1063860955
Provider Name (Legal Business Name): SAMANTHA RAE BRENEMAN LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 05/24/2020
Certification Date: 05/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 GRAND RIVER RD STE 290
BRIGHTON MI
48114-7340
US

IV. Provider business mailing address

7600 GRAND RIVER RD STE 290
BRIGHTON MI
48114-7340
US

V. Phone/Fax

Practice location:
  • Phone: 810-220-2787
  • Fax: 810-220-2834
Mailing address:
  • Phone: 810-220-2787
  • Fax: 810-220-2834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018378
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: