Provider Demographics
NPI:1114613528
Name:RENTERIA, MICHELLE AILEEN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AILEEN
Last Name:RENTERIA
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 1:940 AVENUE 64
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2711
Mailing Address - Country:US
Mailing Address - Phone:323-254-2744
Mailing Address - Fax:
Practice Address - Street 1:940 AVENUE 64
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2711
Practice Address - Country:US
Practice Address - Phone:323-254-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2024-08-28
Deactivation Date:2024-03-11
Deactivation Code:
Reactivation Date:2024-03-19
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA145836106H00000X
CA16491101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)