Healthcare Provider Details

I. General information

NPI: 1669510384
Provider Name (Legal Business Name): BRENN ROBERT GENT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CALO LN
LAKE OZARK MO
65049-9208
US

IV. Provider business mailing address

130 CALO LN
LAKE OZARK MO
65049-9208
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2221
  • Fax: 573-365-2224
Mailing address:
  • Phone: 573-365-2221
  • Fax: 573-365-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007002250
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: