Provider Demographics
NPI:1487745790
Name:BRENNAN, MICHELE JENNIFER (PT, DPT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:JENNIFER
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 VERBENA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-3017
Mailing Address - Country:US
Mailing Address - Phone:323-464-3030
Mailing Address - Fax:
Practice Address - Street 1:9675 BRIGHTON WAY
Practice Address - Street 2:SUITE 250
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5100
Practice Address - Country:US
Practice Address - Phone:310-278-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15074OtherGROUP ID
CAPPINOtherWPT32053A