Provider Demographics
NPI:1487315073
Name:BRENNER, SUSAN CAROLE (LPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROLE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:602-682-7455
Practice Address - Street 1:3330 N 2ND ST STE 601
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2395
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-682-7455
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ199571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86-0485904Medicaid