Basic Information
| Provider Information | |||||||||
| NPI: | 1154405900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENNER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2290 | ||||||||
| Address2: | |||||||||
| City: | KEARNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688482290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3088652767 | ||||||||
| FaxNumber: | 3088652765 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 WEST 33RD STREET | ||||||||
| Address2: | |||||||||
| City: | KEARNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3088652141 | ||||||||
| FaxNumber: | 3082347582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 27 | NE | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 08332 | 01 | BCBS | OTHER | 47064194526 | 05 | NE | MEDICAID |