Provider Demographics
NPI:1760420160
Name:BRENNER, MARY ELIZABETH (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:KENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:23379 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:ACCOMAC
Mailing Address - State:VA
Mailing Address - Zip Code:23301-1314
Mailing Address - Country:US
Mailing Address - Phone:757-787-8284
Mailing Address - Fax:757-787-4931
Practice Address - Street 1:23379 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:ACCOMAC
Practice Address - State:VA
Practice Address - Zip Code:23301-1314
Practice Address - Country:US
Practice Address - Phone:757-787-8284
Practice Address - Fax:757-787-4931
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist