Provider Demographics
NPI:1538595244
Name:BRENNAN, JOHN CHARLES (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 BIDDLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-5231
Mailing Address - Country:US
Mailing Address - Phone:248-470-6225
Mailing Address - Fax:734-324-1566
Practice Address - Street 1:2955 BIDDLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-5231
Practice Address - Country:US
Practice Address - Phone:248-470-6225
Practice Address - Fax:734-324-1566
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014907103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical