Provider Demographics
NPI:1538701750
Name:BRENNAN, LAURA A (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOWDOINHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04008-4420
Mailing Address - Country:US
Mailing Address - Phone:617-765-1228
Mailing Address - Fax:
Practice Address - Street 1:35 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWDOINHAM
Practice Address - State:ME
Practice Address - Zip Code:04008-4420
Practice Address - Country:US
Practice Address - Phone:617-765-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11177103TC0700X, 103T00000X
RIPS01801103TC0700X
MEPS2389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical