Provider Demographics
NPI:1811023773
Name:BRENCKLE, KATHLEEN A (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:BRENCKLE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:8500 BROOKTREE ROAD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9287
Mailing Address - Country:US
Mailing Address - Phone:724-935-6922
Mailing Address - Fax:724-935-6921
Practice Address - Street 1:8500 BROOKTREE ROAD
Practice Address - Street 2:SUITE 230
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9287
Practice Address - Country:US
Practice Address - Phone:724-935-6922
Practice Address - Fax:724-935-6921
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO144801041C0700X
PACW0144801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA204766131OtherTAX IDENTIFICATION NUMBER
PACW014480OtherLCSW - LICENSE NUMBER