Provider Demographics
NPI:1578100376
Name:BRENNAN, WILLIAM MICHAEL
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:BRENNAN
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 1:540 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2467
Mailing Address - Country:US
Mailing Address - Phone:810-664-0391
Mailing Address - Fax:810-664-7079
Practice Address - Street 1:540 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2467
Practice Address - Country:US
Practice Address - Phone:810-664-0391
Practice Address - Fax:810-664-7079
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-30
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020277222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302027722OtherSTATE LICENSE