Provider Demographics
NPI:1225450265
Name:BRENNEMAN, ELYNOR
Entity Type:Individual
Prefix:
First Name:ELYNOR
Middle Name:
Last Name:BRENNEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 STRAW POND WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1810
Mailing Address - Country:US
Mailing Address - Phone:904-928-0112
Mailing Address - Fax:
Practice Address - Street 1:GROWING TOGETHER BEHAVIORAL CENTER
Practice Address - Street 2:6789 SOUTHPOINT PARKWAY BLDG 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-379-6045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLRBT-15-08820106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist