MEDICARE: MR. KENNETH JOHN BRENIMAN LCSW, RYT

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	1041C0700X	Clinical Social Worker	22958	CA
2	225500000X	Respiratory/Developmental/Rehabilitative Specialist/Technologist	25705 YOGA ALLIANCE	CA

General Provider Information

NPI Number	:	1457651689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH JOHN BRENIMAN LCSW, RYT

Provider Business Mailing Address
First Line	:	1511 JEFFERSON ST
Second Line	:	TOWNHOUSE 9
City	:	OAKLAND
State	:	CA
Zip	:	94612-1402
Country	:	US
Telephone Number	:	510-388-2884
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 JEFFERSON ST
Second Line	:	TOWNHOUSE 9
City	:	OAKLAND
State	:	CA
Zip	:	94612-1402
Country	:	US
Telephone Number	:	510-388-2884
Fax Number	:

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

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	10/21/2010

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