Basic Information
| Provider Information | |||||||||
| NPI: | 1962421123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNER | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 LINWOOD AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | WHITINSVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015882068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087918740 | ||||||||
| FaxNumber: | 5087523716 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 LINWOOD AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | WHITINSVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015882068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082347544 | ||||||||
| FaxNumber: | 5082348002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1307 | RI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 16784 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 411874 | 01 | RI | RI BLUE CHIP PIN | OTHER |