Provider Demographics
NPI:1063654523
Name:BRENCICK, MARY (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:BRENCICK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 CASINO DR
Mailing Address - Street 2:
Mailing Address - City:GREENBANK
Mailing Address - State:WA
Mailing Address - Zip Code:98253-9709
Mailing Address - Country:US
Mailing Address - Phone:360-678-9294
Mailing Address - Fax:
Practice Address - Street 1:1300 NE GOLDIE ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4832
Practice Address - Country:US
Practice Address - Phone:360-240-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000085981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical