MEDICARE: KELLY BRENCZEWSKI

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	101YM0800X	Mental Health Counselor	178.019349	IL

General Provider Information

NPI Number	:	1558139667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BRENCZEWSKI

Provider Business Mailing Address
First Line	:	839 BLARNEY RD
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-2942
Country	:	US
Telephone Number	:	815-483-8941
Fax Number	:

Provider Business Practice Location Address
First Line	:	2081 CALISTOGA DR STE 2N
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-4833
Country	:	US
Telephone Number	:	815-320-2410
Fax Number	:

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

Provider Enumeration Date	:	12/18/2023
Last Update Date	:	12/18/2023

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