Provider Demographics
NPI:1700981982
Name:BRENNAN, SUSAN CAROL (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 GULL RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3180
Mailing Address - Country:US
Mailing Address - Phone:218-833-2012
Mailing Address - Fax:
Practice Address - Street 1:18510 HIGHWAY 371 SUITE D
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:218-833-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1153106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123L9BROtherBLUE CROSS
MN371229000Medicaid