Provider Demographics
NPI:1174948160
Name:ANDERSON, RENISE
Entity type:Individual
Prefix:
First Name:RENISE
Middle Name:
Last Name:ANDERSON
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 1:5008 TROPICAL GLEN CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-7228
Mailing Address - Country:US
Mailing Address - Phone:323-841-6822
Mailing Address - Fax:
Practice Address - Street 1:4285 N RANCHO DR STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3455
Practice Address - Country:US
Practice Address - Phone:702-385-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst