Healthcare Provider Details

I. General information

NPI: 1063244515
Provider Name (Legal Business Name): BRENNAN LYNN DAGENHART CADC-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 OPTICAL CT NW
CONCORD NC
28025-0061
US

IV. Provider business mailing address

240 HENNING DR
ALBEMARLE NC
28001-9772
US

V. Phone/Fax

Practice location:
  • Phone: 980-270-5500
  • Fax:
Mailing address:
  • Phone: 336-422-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number30157
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30157
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: