Provider Demographics
NPI:1770794687
Name:LIEBOLD, BRENNA TATIANA (MT-BC, WMTR)
Entity type:Individual
Prefix:MS
First Name:BRENNA
Middle Name:TATIANA
Last Name:LIEBOLD
Suffix:
Gender:F
Credentials:MT-BC, WMTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 W LAYTON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4572
Mailing Address - Country:US
Mailing Address - Phone:262-682-3223
Mailing Address - Fax:
Practice Address - Street 1:6520 W LAYTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4572
Practice Address - Country:US
Practice Address - Phone:262-682-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86-038225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist