Provider Demographics
NPI:1760149652
Name:BRENNAN, SELENA MAREE (ATC)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:MAREE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8243 CARIBOU LAKE LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1984
Mailing Address - Country:US
Mailing Address - Phone:248-563-3314
Mailing Address - Fax:
Practice Address - Street 1:8243 CARIBOU LAKE LN
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-1984
Practice Address - Country:US
Practice Address - Phone:248-563-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
MI20000422512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer