Provider Demographics
NPI:1689639189
Name:BRENNER, GEORGE B (LCSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:B
Last Name:BRENNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5470 E 16TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4861
Practice Address - Country:US
Practice Address - Phone:317-355-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000397A106H00000X
IN34002846A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN000000386704OtherANTHEM-GALLAHUE MENTAL HEALTH SERVICES
IN150074Medicare PIN
IN000000386704OtherANTHEM-GALLAHUE MENTAL HEALTH SERVICES
INM400051217Medicare PIN
IN100270530AMedicaid