Healthcare Provider Details

I. General information

NPI: 1154314870
Provider Name (Legal Business Name): DIANA J BRENNER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 COPELAND MILL RD 1E
WESTERVILLE OH
43081-8977
US

IV. Provider business mailing address

4546 STARRETT RD
COLUMBUS OH
43214-2527
US

V. Phone/Fax

Practice location:
  • Phone: 614-882-0021
  • Fax: 614-882-1593
Mailing address:
  • Phone: 614-882-0021
  • Fax: 614-882-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4670
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: