1073611679 NPI number — DR. MARY MAUREEN BRENNAN PH.D.

Table of content: TODD H WOLYNN MD (NPI 1205835592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073611679 NPI number — DR. MARY MAUREEN BRENNAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNAN
Provider First Name:
MARY
Provider Middle Name:
MAUREEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073611679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 CAILLOUETT PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70501-7807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-234-4912
Provider Business Mailing Address Fax Number:
337-234-6064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 CAILLOUETT PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70501-7807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-234-4912
Provider Business Practice Location Address Fax Number:
337-234-6064
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  460 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com