Healthcare Provider Details

I. General information

NPI: 1497884167
Provider Name (Legal Business Name): DORI ILENE BRENNER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 W MAIN ST SECOND FLOOR
PATCHOGUE NY
11772-3012
US

IV. Provider business mailing address

40 W 4TH ST APT 158
PATCHOGUE NY
11772-2134
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-2170
  • Fax:
Mailing address:
  • Phone: 631-758-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number008877-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: