Provider Demographics
NPI:1982894622
Name:BRENNER, ANGIE FAITH (LICSW)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:FAITH
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MIDDLESEX AVE.
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887
Mailing Address - Country:US
Mailing Address - Phone:978-658-9889
Mailing Address - Fax:978-658-5695
Practice Address - Street 1:5 MIDDLESEX AVE.
Practice Address - Street 2:SUITE 11
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887
Practice Address - Country:US
Practice Address - Phone:978-658-9889
Practice Address - Fax:978-658-5695
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1138081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical