Basic Information
| Provider Information | |||||||||
| NPI: | 1982235925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRABENEC | ||||||||
| FirstName: | MCKENNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BHIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 E MAIN ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143557570 | ||||||||
| FaxNumber: | 6143557580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |