Provider Demographics
NPI:1255348066
Name:BRENNER, ANN SUSAN (MARRIAGE AND FAMILY)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:SUSAN
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MARRIAGE AND FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WOODS GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-2427
Mailing Address - Country:US
Mailing Address - Phone:203-226-0464
Mailing Address - Fax:203-226-0464
Practice Address - Street 1:31 WOODS GROVE RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-2427
Practice Address - Country:US
Practice Address - Phone:203-226-0464
Practice Address - Fax:203-226-0464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000432-1106H00000X
CT000486106H00000X
CAMFC15135106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11561882OtherCAQH
CT410000486CT01OtherANTHEM BLUE CROSS