Provider Demographics
NPI:1710512611
Name:HENNINGTON, BRIEANNA TYCHELLE
Entity Type:Individual
Prefix:
First Name:BRIEANNA
Middle Name:TYCHELLE
Last Name:HENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 HIGH RIDGE TRL APT 202
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3681
Mailing Address - Country:US
Mailing Address - Phone:317-200-6392
Mailing Address - Fax:
Practice Address - Street 1:702 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1424
Practice Address - Country:US
Practice Address - Phone:608-444-1372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health