Provider Demographics
NPI:1750438230
Name:BRENNER, KENNIE CECILIA (PT)
Entity type:Individual
Prefix:MRS
First Name:KENNIE
Middle Name:CECILIA
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:KENNIE
Other - Middle Name:CECILIA
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:14555 LEVAN RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5083
Mailing Address - Country:US
Mailing Address - Phone:734-542-9770
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 215
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501012245OtherPHYSICAL THERAPIST
MI5501012245OtherPHYSICAL THERAPIST