Provider Demographics
NPI:1487323010
Name:BRENNER, ELISSA
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 PRATT ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-8627
Mailing Address - Country:US
Mailing Address - Phone:203-235-5767
Mailing Address - Fax:203-238-2010
Practice Address - Street 1:384 PRATT ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-8627
Practice Address - Country:US
Practice Address - Phone:203-235-5767
Practice Address - Fax:203-238-2010
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2022-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002678106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist