=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225353121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA BRENNAN LCSW-R
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2010
-----------------------------------------------------
Last Update Date | 10/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 BELL BLVD SUITE 203
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-830-0246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98120 QUEENS BLVD SUITE 1C
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-4357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-830-0246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R078039
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------