Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | 6401014593 | MI |
Y | 103TH0100X | Health Service |
NPI | 1295196152 |
---|---|
Provider Name | Edwin Brennan |
First Address | Berrien Springs, MI 49103-1430 |
Second Address | Berrien Springs, MI 49103-1430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2016 |
Last Update Date | 15/12/2020 |