Provider Demographics
NPI:1386797355
Name:BRENNER, MARK JEFFERY (PHD, LICSW)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFERY
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NATHANIEL WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-3852
Mailing Address - Country:US
Mailing Address - Phone:781-821-0708
Mailing Address - Fax:
Practice Address - Street 1:1 NATHANIEL WAY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-3852
Practice Address - Country:US
Practice Address - Phone:781-821-0708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1048401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical