Provider Demographics
NPI:1922687656
Name:CARLSON, BRENNA A (MA)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7905 OLD AMISH RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:WI
Mailing Address - Zip Code:54406-9190
Mailing Address - Country:US
Mailing Address - Phone:715-347-3046
Mailing Address - Fax:
Practice Address - Street 1:200 N PATRICK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5883
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI425-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst