Provider Demographics
NPI:1063947893
Name:RENNER, LISA (LMSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RENNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NATUREVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1431
Mailing Address - Country:US
Mailing Address - Phone:203-731-4570
Mailing Address - Fax:
Practice Address - Street 1:11 NATUREVIEW TRL
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1431
Practice Address - Country:US
Practice Address - Phone:203-731-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003052104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker