Provider Demographics
NPI:1760241137
Name:BRENNAN, DYLAN MALACHI
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:MALACHI
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4441
Mailing Address - Country:US
Mailing Address - Phone:918-687-7064
Mailing Address - Fax:918-683-1983
Practice Address - Street 1:1139 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4441
Practice Address - Country:US
Practice Address - Phone:918-687-7064
Practice Address - Fax:918-683-1983
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator