Basic Information
| Provider Information | |||||||||
| NPI: | 1396268173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | CENTRACARE CLINIC HEALTH PLAZA/PEDIATRICS & ADOLESCENT | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR # 1300 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | 3206543647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2017 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 9654 | MN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.