{
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"ReplacementNPI": null,
"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "BERNADETTE L. BRENNECKE, LCSW, INC.",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"FirstLineMailingAddress": "640 S. SUNSET AVE",
"SecondLineMailingAddress": "SUITE 102",
"MailingAddressCityName": "WEST COVINA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91790",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-263-0851",
"MailingAddressFaxNumber": "626-338-9022",
"FirstLinePracticeLocationAddress": "4574 LIVE OAK CANYON ROAD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "LA VERNE",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91750",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-263-0851",
"PracticeLocationAddressFaxNumber": "626-338-9022",
"EnumerationDate": "04/01/2010",
"LastUpdateDate": "03/06/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PETROPOULOS",
"AuthorizedOfficialFirstName": "GREG",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER/THERAPIST",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LMFT",
"AuthorizedOfficialTelephoneNumber": "909-263-0934",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": "MFC 37681",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}