1306391453 NPI number — CLARA ELISA BRENNECKE M.A. LCPC

Table of content: CLARA ELISA BRENNECKE M.A. LCPC (NPI 1306391453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306391453 NPI number — CLARA ELISA BRENNECKE M.A. LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNECKE
Provider First Name:
CLARA
Provider Middle Name:
ELISA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A. LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRENNECKE
Provider Other First Name:
CLARA
Provider Other Middle Name:
ELISA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306391453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1122 W HUBBARD ST
Provider Second Line Business Mailing Address:
UNIT 3E
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60642-8805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1122 W HUBBARD ST
Provider Second Line Business Practice Location Address:
UNIT 3E
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60642-8805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-405-2784
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2016

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: 101YM0800X , with the licence number:  180.010376 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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