=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396933727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANYELL LYNN BRENNER LCSW, BCD, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2007
-----------------------------------------------------
Last Update Date | 11/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BROOKE ARMY MEDICAL CENTER 3551 ROGER BROOKE DR.
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-888-2213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PSC 482 BOX 2714
-----------------------------------------------------
City | FPO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96362 2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-643-7722
-----------------------------------------------------
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 | 149011014
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------