Provider Demographics
NPI:1669885935
Name:BRENNAN, SUSAN IRENE (LAC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:IRENE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-4305
Mailing Address - Country:US
Mailing Address - Phone:845-675-7826
Mailing Address - Fax:
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-4305
Practice Address - Country:US
Practice Address - Phone:845-675-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002909171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist