Provider Demographics
NPI:1114937257
Name:BRENNER, JOSEPH EDWIN (DPT)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:EDWIN
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1686
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382
Mailing Address - Country:US
Mailing Address - Phone:360-504-2390
Mailing Address - Fax:360-785-6055
Practice Address - Street 1:158 W. SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-504-2390
Practice Address - Fax:360-785-6055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60665590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT85121Medicaid
AKPT85121Medicaid