Provider Demographics
NPI:1023041191
Name:BRENNEMAN, MARY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BRENNEMAN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7827 WISE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-3339
Mailing Address - Country:US
Mailing Address - Phone:410-282-7222
Mailing Address - Fax:410-282-0069
Practice Address - Street 1:7827 WISE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-3339
Practice Address - Country:US
Practice Address - Phone:410-282-7222
Practice Address - Fax:410-282-0069
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04998104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD436LO329Medicare PIN