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General NPI Number Information
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NPI Number | 1407379555
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Entity Type | Individual
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Provider Name | JOHNATHAN BRENNER MA, ED.S.
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Gender | Male
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Dates
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Enumeration Date | 07/20/2017
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Last Update Date | 07/20/2017
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Provider Practice Location Address
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Address Line | 125 FAIRFIELD WAY
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1597
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Country | US
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Telephone | 630-440-5406
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Fax |
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Provider Business Mailing Address
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Address Line | 1691 JOSEPH CT
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-6892
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Country | US
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Telephone | 847-778-7156
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 2056540
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License Number State | IL
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