Provider Demographics
NPI:1508870759
Name:BRENNER, KIMBERLY H (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:H
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9610 FRANKLIN AVE APT 518
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2793
Mailing Address - Country:US
Mailing Address - Phone:915-491-5709
Mailing Address - Fax:
Practice Address - Street 1:222 S PROSPECT AVE FL 3
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4037
Practice Address - Country:US
Practice Address - Phone:915-491-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236911041C0700X
TX326911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0073KMOtherBLUE CROSS BLUE SHIELD
TX32449033Medicaid
TX515889OtherVALUE OPTIONS
TX555122000OtherMAGELLAN
TX159603301Medicaid
TX0073KMOtherBLUE CROSS BLUE SHIELD