Provider Demographics
NPI:1063276954
Name:RENDON, RENATA VIRIDIANA
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:VIRIDIANA
Last Name:RENDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 NATIONAL CITY BLVD
Mailing Address - Street 2:APARMENT 422
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950
Mailing Address - Country:US
Mailing Address - Phone:619-517-8054
Mailing Address - Fax:
Practice Address - Street 1:1125 NATIONAL CITY BLVD
Practice Address - Street 2:APARMENT 422
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950
Practice Address - Country:US
Practice Address - Phone:619-517-8054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-387593106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician