Basic Information
| Provider Information | |||||||||
| NPI: | 1518323369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | LPC, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2016 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 21265 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 10804 | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C4915 | OR | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 10804 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 170061 | 05 | OR | MEDICAID |