Provider Demographics
NPI:1992807465
Name:BRENNER, EDWARD (PSYD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:BRENNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-677-0235
Mailing Address - Fax:
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 215
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-677-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009667103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV63621Medicare ID - Type Unspecified