Healthcare Provider Details

I. General information

NPI: 1043747306
Provider Name (Legal Business Name): ERIN BRENNER QMHS, LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL # 1040
DAYTON OH
45417-3445
US

IV. Provider business mailing address

1934 W BATAAN DR
KETTERING OH
45420-3643
US

V. Phone/Fax

Practice location:
  • Phone: 937-732-0571
  • Fax:
Mailing address:
  • Phone: 937-732-0571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162100
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: