Basic Information
| Provider Information | |||||||||
| NPI: | 1720685381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSOT R/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEL BUSTO | ||||||||
| OtherFirstName: | NICOLE | ||||||||
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| OtherCredential: | MSOT R/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 GRANBY ST STE B | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235041312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574238885 | ||||||||
| FaxNumber: | 7574238886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119008759 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.