Provider Demographics
NPI:1962421123
Name:BRENNER, LAURIE BETH (MSPT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:BETH
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 LINWOOD AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-2068
Mailing Address - Country:US
Mailing Address - Phone:508-791-8740
Mailing Address - Fax:508-752-3716
Practice Address - Street 1:670 LINWOOD AVE STE 2
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-2068
Practice Address - Country:US
Practice Address - Phone:508-234-7544
Practice Address - Fax:508-234-8002
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT1307225100000X
MA16784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI411874OtherRI BLUE CHIP PIN
RI411874OtherRI BLUE CHIP PIN