Provider Demographics
NPI:1083884506
Name:BRENNER, MELINDA MAE (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MAE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 WESTWOOD AVE
Mailing Address - Street 2:UNIT 48
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-5565
Mailing Address - Country:US
Mailing Address - Phone:732-233-5796
Mailing Address - Fax:732-601-7069
Practice Address - Street 1:364 WESTWOOD AVE
Practice Address - Street 2:UNIT 48
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-5565
Practice Address - Country:US
Practice Address - Phone:732-233-5796
Practice Address - Fax:732-601-7069
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000863002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer