Provider Demographics
NPI:1972728129
Name:BRENNER, ELIOT MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIOT
Middle Name:MICHAEL
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 CASMIR DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1227
Mailing Address - Country:US
Mailing Address - Phone:203-373-0438
Mailing Address - Fax:
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6016
Practice Address - Country:US
Practice Address - Phone:203-209-9535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002434103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical