MEDICARE: TAMARA BRENNAN

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1720468796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA BRENNAN

Provider Business Mailing Address
First Line	:	19897 LAKEWOOD DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61705-4003
Country	:	US
Telephone Number	:	309-830-7969
Fax Number	:

Provider Business Practice Location Address
First Line	:	19897 LAKEWOOD DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61705-4003
Country	:	US
Telephone Number	:	309-830-7969
Fax Number	:

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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Directions to “ TAMARA BRENNAN ” Practice Location

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