Provider Demographics
NPI:1376077339
Name:PENQUE, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:PENQUE
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 1:230 S FRONTAGE RD
Mailing Address - Street 2:CHILD STUDY CENTER ATN: TANYA COLON
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1124
Mailing Address - Country:US
Mailing Address - Phone:203-737-7129
Mailing Address - Fax:
Practice Address - Street 1:230 S FRONTAGE RD
Practice Address - Street 2:CHILD STUDY CENTER ATN: TANYA COLON
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1124
Practice Address - Country:US
Practice Address - Phone:203-737-7129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT637842084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program