Provider Demographics
NPI:1275756017
Name:BRENNECKE, BERNADETTE LEILANI (LSCW)
Entity Type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:LEILANI
Last Name:BRENNECKE
Suffix:
Gender:F
Credentials:LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S SUNSET AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2808
Mailing Address - Country:US
Mailing Address - Phone:909-263-0851
Mailing Address - Fax:626-338-9022
Practice Address - Street 1:4574 LIVE OAK CANYON RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2312
Practice Address - Country:US
Practice Address - Phone:909-263-0851
Practice Address - Fax:626-338-9022
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALG 106771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM0990601OtherDRIVERS LICENSE NUMBER