Healthcare Provider Details

I. General information

NPI: 1912861147
Provider Name (Legal Business Name): BRENTON MCLEAN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 BRICK BLVD STE 204
BRICK NJ
08723-7984
US

IV. Provider business mailing address

74 BRICK BLVD STE 204
BRICK NJ
08723-7984
US

V. Phone/Fax

Practice location:
  • Phone: 732-832-3444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37AC00927700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: