Provider Demographics
NPI:1750557849
Name:BRENNAN, MARTINA
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TYRE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7136
Mailing Address - Country:US
Mailing Address - Phone:302-454-2047
Mailing Address - Fax:302-454-5443
Practice Address - Street 1:200 TYRE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7136
Practice Address - Country:US
Practice Address - Phone:302-454-2047
Practice Address - Fax:302-454-5443
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0000252225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000803767Medicaid