Provider Demographics
NPI:1265990600
Name:BRENNER, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CHESTNUT WOODS CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-5523
Mailing Address - Country:US
Mailing Address - Phone:443-324-3405
Mailing Address - Fax:
Practice Address - Street 1:5022 CAMPBELL BLVD STE L
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:443-442-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24561104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD02021970Medicaid