Provider Demographics
NPI:1366893760
Name:GENNETT, BRIAN (LCDC II)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GENNETT
Suffix:
Gender:M
Credentials:LCDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6434 E MAIN ST
Mailing Address - Street 2:201
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7300
Mailing Address - Country:US
Mailing Address - Phone:614-762-2847
Mailing Address - Fax:614-762-2984
Practice Address - Street 1:6434 E MAIN ST
Practice Address - Street 2:201
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7300
Practice Address - Country:US
Practice Address - Phone:614-762-2847
Practice Address - Fax:614-762-2984
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)