Provider Demographics
NPI:1144682667
Name:BRENNER, VIRGINIA (MS)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ESCALLE LN
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1216
Mailing Address - Country:US
Mailing Address - Phone:415-927-2767
Mailing Address - Fax:415-461-4626
Practice Address - Street 1:23 ESCALLE LN
Practice Address - Street 2:980 MAGNOLIA AVE.
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1216
Practice Address - Country:US
Practice Address - Phone:415-927-2767
Practice Address - Fax:415-461-4626
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP652103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent