Provider Demographics
NPI:1417233297
Name:BRENNER, ANGELA (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 SAN AUGUSTINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2260
Mailing Address - Country:US
Mailing Address - Phone:858-793-4496
Mailing Address - Fax:858-793-5461
Practice Address - Street 1:3944 SAN AUGUSTINE WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2260
Practice Address - Country:US
Practice Address - Phone:858-793-4496
Practice Address - Fax:858-793-5461
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist