Provider Demographics
NPI:1043747306
Name:BRENNER, ERIN (QMHS, LCDC III)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:QMHS, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 W BATAAN DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-3643
Mailing Address - Country:US
Mailing Address - Phone:937-732-0571
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL # 1040
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-732-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHLCDCIII.162100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health