Provider Demographics
NPI:1992434914
Name:EKDOM, BRENNAN KYLEE
Entity type:Individual
Prefix:MRS
First Name:BRENNAN
Middle Name:KYLEE
Last Name:EKDOM
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 1:4860 FIELDSTONE LN APT 20
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8998
Mailing Address - Country:US
Mailing Address - Phone:989-942-4267
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5312
Practice Address - Country:US
Practice Address - Phone:248-299-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician