MEDICARE: C. BROOKS BRENNEIS PH. D.

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	103T00000X	Psychologist	573057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710918628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	C. BROOKS BRENNEIS PH. D.

Provider Business Mailing Address
First Line	:	313 PRICE PL STE 203
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-3262
Country	:	US
Telephone Number	:	608-238-2301
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 PRICE PL STE 203
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-3262
Country	:	US
Telephone Number	:	608-238-2301
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	09/13/2007

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