Healthcare Provider Details

I. General information

NPI: 1124617360
Provider Name (Legal Business Name): NICHOLAS PATRICK BRENNAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 SW 13TH ST
BEND OR
97702-3184
US

IV. Provider business mailing address

548 SW 13TH ST
BEND OR
97702-3184
US

V. Phone/Fax

Practice location:
  • Phone: 458-207-6299
  • Fax:
Mailing address:
  • Phone: 458-207-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

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: