MEDICARE: KATELIN LEE ANN KELLEY RENOUF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1396504221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELIN LEE ANN KELLEY RENOUF

Provider Business Mailing Address
First Line	:	809 17TH TER NE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4427
Country	:	US
Telephone Number	:	870-321-2979
Fax Number	:

Provider Business Practice Location Address
First Line	:	809 17TH TER NE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4427
Country	:	US
Telephone Number	:	870-321-2979
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2024
Last Update Date	:	03/14/2024

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