Provider Demographics
NPI:1346892288
Name:BRENNEMAN, ROBERT KIRK
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KIRK
Last Name:BRENNEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 E DOROTHY LN APT 21
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3860
Mailing Address - Country:US
Mailing Address - Phone:937-977-3043
Mailing Address - Fax:
Practice Address - Street 1:3908 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5070
Practice Address - Country:US
Practice Address - Phone:937-222-7349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168368101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)