Provider Demographics
NPI:1073701124
Name:BRENNER, MOLLY (PT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SUPERIOR AVE
Mailing Address - Street 2:B
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2712
Mailing Address - Country:US
Mailing Address - Phone:714-280-0267
Mailing Address - Fax:714-280-9511
Practice Address - Street 1:1441 SUPERIOR AVE
Practice Address - Street 2:B
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2712
Practice Address - Country:US
Practice Address - Phone:714-280-0267
Practice Address - Fax:714-280-9511
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT1266208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT1266OtherSTATE LICENSE