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NPI Code Detail

MEDICARE: LISA M BRENNOM LICSW

MEDICARE: LISA M BRENNOM LICSW
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
11041C0700XClinical Social Worker13588MS

General Provider Information

NPI Number : 1437179611
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA M BRENNOM LICSW
Provider Business Mailing Address
First Line : 3395 PLYMOUTH RD
Second Line :
City : MINNETONKA
State : MN
Zip : 55305-3765
Country : US
Telephone Number : 952-567-9259
Fax Number :
Provider Business Practice Location Address
First Line : 3395 PLYMOUTH RD
Second Line :
City : MINNETONKA
State : MN
Zip : 55305-3765
Country : US
Telephone Number : 952-939-0396
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2006
Last Update Date : 05/03/2018

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