Provider Demographics
NPI:1023887882
Name:DUBICK, BRENNA
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:DUBICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N 12TH PL APT 14
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3120
Mailing Address - Country:US
Mailing Address - Phone:920-493-7675
Mailing Address - Fax:
Practice Address - Street 1:1241 S GLENDALE AVE STE 203
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3388
Practice Address - Country:US
Practice Address - Phone:510-440-1383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT304991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist