Basic Information
| Provider Information | |||||||||
| NPI: | 1063654523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENCICK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 CASINO DR | ||||||||
| Address2: | |||||||||
| City: | GREENBANK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982539709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606789294 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 NE GOLDIE ST | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982774832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602404043 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00008598 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.