Provider Demographics
NPI:1871277434
Name:BRENNAN, MYLES THOMAS
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:THOMAS
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 REDWOOD WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1136
Mailing Address - Country:US
Mailing Address - Phone:707-806-9972
Mailing Address - Fax:707-868-6003
Practice Address - Street 1:1301 REDWOOD WAY STE 210
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1107
Practice Address - Country:US
Practice Address - Phone:707-806-9921
Practice Address - Fax:707-868-6003
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty