=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477013985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL RUTH BRENTNER LPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2019
-----------------------------------------------------
Last Update Date | 03/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 GRAVES MILL RD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-404-9665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2009 LAKESIDE DR UNIT 210
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24501-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-404-9665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0701007855
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------