Provider Demographics
NPI:1306885405
Name:BRENNER, LISA M (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:BRENNER
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
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Mailing Address - Street 1:758 CHAMBERLAIN PL
Mailing Address - Street 2:SUITE101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2716
Mailing Address - Country:US
Mailing Address - Phone:314-963-9999
Mailing Address - Fax:
Practice Address - Street 1:758 CHAMBERLAIN PL
Practice Address - Street 2:SUITE101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2716
Practice Address - Country:US
Practice Address - Phone:314-963-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOPY01812103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2110205OtherFIRST HEALTH
MO498577113Medicaid
MO179641OtherBLUE CROSS BLUE SHIELD
MO216258OtherCOMPSYCH
MO2110205OtherCCN
MO338175OtherMANAGED HEALTH NETWORK
MO628448OtherHEALTHLINK HMO/PPO
MO2110205OtherFIRST HEALTH