Provider Demographics
NPI:1962604348
Name:RENAUD, KRISTINA MARIE (BS, RSST)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:RENAUD
Suffix:
Gender:F
Credentials:BS, RSST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2036
Mailing Address - Country:US
Mailing Address - Phone:313-389-7598
Mailing Address - Fax:313-389-7515
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-7598
Practice Address - Fax:313-389-7515
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803074970104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker