Provider Demographics
NPI:1306391453
Name:BRENNECKE, CLARA ELISA (MA LCPC)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:ELISA
Last Name:BRENNECKE
Suffix:
Gender:F
Credentials:MA LCPC
Other - Prefix:
Other - First Name:CLARA
Other - Middle Name:ELISA
Other - Last Name:BRENNECKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1122 W HUBBARD ST
Mailing Address - Street 2:UNIT 3E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-8805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 W HUBBARD ST
Practice Address - Street 2:UNIT 3E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-8805
Practice Address - Country:US
Practice Address - Phone:312-405-2784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health