Provider Demographics
NPI:1154314870
Name:BRENNER, DIANA J (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:J
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4546 STARRETT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2527
Mailing Address - Country:US
Mailing Address - Phone:614-882-0021
Mailing Address - Fax:614-882-1593
Practice Address - Street 1:575 COPELAND MILL RD
Practice Address - Street 2:1E
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8977
Practice Address - Country:US
Practice Address - Phone:614-882-0021
Practice Address - Fax:614-882-1593
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4670103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBRCP13361Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST