Provider Demographics
NPI:1356494801
Name:BRENNAN, MARILYN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E WALNUT ST
Mailing Address - Street 2:SUITE 706
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4239
Mailing Address - Country:US
Mailing Address - Phone:920-437-8256
Mailing Address - Fax:920-437-1188
Practice Address - Street 1:130 E WALNUT ST
Practice Address - Street 2:SUITE 706
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4239
Practice Address - Country:US
Practice Address - Phone:920-437-8256
Practice Address - Fax:920-437-1188
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39740800Medicaid
WI39740800Medicaid