Provider Demographics
NPI:1588315832
Name:RENNAKER, LARISSA LANAE
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:LANAE
Last Name:RENNAKER
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 1:4070 TURNBERRY CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1719
Mailing Address - Country:US
Mailing Address - Phone:719-252-2984
Mailing Address - Fax:
Practice Address - Street 1:2105 ACADEMY CIR STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1664
Practice Address - Country:US
Practice Address - Phone:719-252-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-21-193091106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician