Provider Demographics
NPI:1912282286
Name:BRENNEMAN, TERRI J (PHD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:J
Last Name:BRENNEMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5907
Mailing Address - Country:US
Mailing Address - Phone:574-534-6150
Mailing Address - Fax:574-534-8139
Practice Address - Street 1:1908 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5907
Practice Address - Country:US
Practice Address - Phone:574-534-6150
Practice Address - Fax:574-534-8139
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042219A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP13412AMedicare PIN