Provider Demographics
NPI:1205902244
Name:BRENNAN, MARY T (MS, SLP)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:T
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1452
Mailing Address - Street 2:5577 VANBARR PLACE, SUITE 7
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-1452
Mailing Address - Country:US
Mailing Address - Phone:360-331-8001
Mailing Address - Fax:360-331-8009
Practice Address - Street 1:5577 VANBARR PLACE
Practice Address - Street 2:SUITE 7
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-8001
Practice Address - Fax:360-331-8001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003055235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7028319Medicaid
WA364584100000OtherPREMERA BLUE CROSS
WA5388BROtherREGENCE PROVIDER NUMBER
WA8454814Medicaid
WA7101821OtherAETNA PROVIDER NUMBER