Provider Demographics
NPI:1174959506
Name:MALLETT, RENAE (MA, LPC)
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:MALLETT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:4390 N ACADEMY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6657
Mailing Address - Country:US
Mailing Address - Phone:719-301-9496
Mailing Address - Fax:
Practice Address - Street 1:4390 N ACADEMY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6657
Practice Address - Country:US
Practice Address - Phone:719-301-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0006395101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health