Provider Demographics
NPI:1578552162
Name:BRENNER, PAUL FREDERICK (DSW)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:FREDERICK
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3131
Mailing Address - Country:US
Mailing Address - Phone:732-389-2484
Mailing Address - Fax:732-389-2014
Practice Address - Street 1:929 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-3131
Practice Address - Country:US
Practice Address - Phone:732-389-2484
Practice Address - Fax:732-389-2014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000216001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ501267Medicare ID - Type Unspecified