MEDICARE: DR. LAURENCE BRENNER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1063580439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURENCE BRENNER PHD

Provider Business Mailing Address
First Line	:	366 ROOSEVELT WAY
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94114-1434
Country	:	US
Telephone Number	:	415-861-4788
Fax Number	:

Provider Business Practice Location Address
First Line	:	1348 10TH AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94122-2304
Country	:	US
Telephone Number	:	415-564-2310
Fax Number	:	415-564-2313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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