1508870759 NPI number — KIMBERLY H BRENNER LCSW

Table of content: KIMBERLY H BRENNER LCSW (NPI 1508870759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508870759 NPI number — KIMBERLY H BRENNER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNER
Provider First Name:
KIMBERLY
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1508870759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9610 FRANKLIN AVE APT 518
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60131-2793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-491-5709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S PROSPECT AVE FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60068-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-491-5709
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

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: 1041C0700X , with the licence number:  23691 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 32691 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0073KM . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 32449033 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 515889 . This is a "VALUE OPTIONS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 555122000 . This is a "MAGELLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 159603301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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