Provider Demographics
NPI:1063471498
Name:BRENNA, BENJAMIN JOHN (PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:BRENNA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9138
Mailing Address - Country:US
Mailing Address - Phone:715-822-6167
Mailing Address - Fax:715-822-6142
Practice Address - Street 1:205 OAK ST
Practice Address - Street 2:
Practice Address - City:TURTLE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54889-8929
Practice Address - Country:US
Practice Address - Phone:715-986-2022
Practice Address - Fax:715-986-2236
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5791-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84587-0007Medicaid
WI40314000OtherMEDICAL ASSISTANCE