Provider Demographics
NPI:1003536343
Name:PEDERSEN, BRENNAN
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BUTLER ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-4989
Mailing Address - Country:US
Mailing Address - Phone:206-890-7816
Mailing Address - Fax:
Practice Address - Street 1:31 WASHINGTON SQ W STE 6B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-9126
Practice Address - Country:US
Practice Address - Phone:206-890-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001153103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis