Provider Demographics
NPI:1396904108
Name:BREHM, MARY ELLEN (MED)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:BREHM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:571 S FLOYD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3818
Mailing Address - Country:US
Mailing Address - Phone:502-852-7897
Mailing Address - Fax:502-852-2911
Practice Address - Street 1:571 S FLOYD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3818
Practice Address - Country:US
Practice Address - Phone:502-852-7897
Practice Address - Fax:502-852-2911
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2008-17103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent