MEDICARE: BRENT ALAN JEREMY LCSW

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	SW 4445	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AH367Z	OTHER	FL	PTAN

General Provider Information

NPI Number	:	1811100845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT ALAN JEREMY LCSW

Provider Business Mailing Address
First Line	:	5729 W 1ST SQ SW
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32968-2253
Country	:	US
Telephone Number	:	772-562-4852
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 20TH ST.
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3026
Country	:	US
Telephone Number	:	772-567-6508
Fax Number	:

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	02/10/2008

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