Provider Demographics
NPI:1669506416
Name:BRENNEMAN, MONA GAY (BS IN SOCIAL WORK)
Entity Type:Individual
Prefix:MRS
First Name:MONA
Middle Name:GAY
Last Name:BRENNEMAN
Suffix:
Gender:F
Credentials:BS IN SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-6133
Mailing Address - Country:US
Mailing Address - Phone:580-749-5056
Mailing Address - Fax:580-215-5756
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:580-215-5756
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00815101YA0400X
OK1028101YA0400X
KS03353101YP2500X
OK5910101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional