Provider Demographics
NPI:1093864266
Name:BRENNER, MARLIN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARLIN
Middle Name:S
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WEST 88 ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024
Mailing Address - Country:US
Mailing Address - Phone:212-873-9440
Mailing Address - Fax:212-877-9709
Practice Address - Street 1:255 WEST 88 ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:212-873-9440
Practice Address - Fax:212-877-9709
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPSY002738 1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0054012OtherGHI
145274OtherVALVE OPTIONS
0054012OtherGHI