1306885405 NPI number — DR. LISA M. BRENNER PSYCHOLOGIST

Table of content: DR. LISA M. BRENNER PSYCHOLOGIST (NPI 1306885405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306885405 NPI number — DR. LISA M. BRENNER PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNER
Provider First Name:
LISA
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGIST
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:
1306885405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
758 CHAMBERLAIN PL
Provider Second Line Business Mailing Address:
SUITE101
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63119-2716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-963-9999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
758 CHAMBERLAIN PL
Provider Second Line Business Practice Location Address:
SUITE101
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63119-2716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-963-9999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2006

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:  PY01812 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2110205 . This is a "FIRST HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 498577113 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 179641 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 216258 . This is a "COMPSYCH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2110205 . This is a "CCN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 338175 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 628448 . This is a "HEALTHLINK HMO/PPO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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