Provider Demographics
NPI:1104360445
Name:BRENNER, AERIEL (QASP)
Entity Type:Individual
Prefix:
First Name:AERIEL
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:QASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W BIG BEAVER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3535
Mailing Address - Country:US
Mailing Address - Phone:248-918-5600
Mailing Address - Fax:
Practice Address - Street 1:10175 FORTUNE PKWY UNIT 903
Practice Address - Street 2:SUITE 903
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6755
Practice Address - Country:US
Practice Address - Phone:904-538-0713
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-15-05021106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician