Healthcare Provider Details

I. General information

NPI: 1245738418
Provider Name (Legal Business Name): DR. JOHN C BRENNAN PSYD, LP, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 BIDDLE AVE STE 200
WYANDOTTE MI
48192-5231
US

IV. Provider business mailing address

2955 BIDDLE AVE STE 200
WYANDOTTE MI
48192-5231
US

V. Phone/Fax

Practice location:
  • Phone: 249-698-8993
  • Fax: 734-324-1566
Mailing address:
  • Phone: 249-698-8993
  • Fax: 734-324-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014907
License Number StateMI

VIII. Authorized Official

Name: DR. JOHN CHARLES BRENNAN
Title or Position: SOLE PROPIETOR
Credential: PSYD, LP
Phone: 248-470-6225