Provider Demographics
NPI:1922031327
Name:BRENNEISE, CORAL ANNE (MSW)
Entity Type:Individual
Prefix:MS
First Name:CORAL
Middle Name:ANNE
Last Name:BRENNEISE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N KIMMEL ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1121
Mailing Address - Country:US
Mailing Address - Phone:269-473-2507
Mailing Address - Fax:
Practice Address - Street 1:115 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3663
Practice Address - Country:US
Practice Address - Phone:269-934-9123
Practice Address - Fax:269-934-9347
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010866471041C0700X
IN34004736A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical