Basic Information
| Provider Information | |||||||||
| NPI: | 1962604348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENAUD | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | B.S., R.S.S.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1259 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133897598 | ||||||||
| FaxNumber: | 3133897515 | ||||||||
| Practice Location | |||||||||
| Address1: | 26184 OUTER DR | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133897598 | ||||||||
| FaxNumber: | 3133897515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6803074970 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.