Basic Information
| Provider Information | |||||||||
| NPI: | 1750849063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENDEROS | ||||||||
| FirstName: | DANNY | ||||||||
| MiddleName: | ERNESTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 CALLE CHAPULTEPIC | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077613523 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2751 NAPA VALLEY CORPORATE DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072534279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2019 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT109526 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | AMFT109526 | 01 | CA | AMFT | OTHER |