MEDICARE: STEPHANIE AMBER RENEAU

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	225X00000X	Occupational Therapist	133771	KY
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1518596055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE AMBER RENEAU

Provider Business Mailing Address
First Line	:	1074 VIRGINIA AVE
Second Line	:
City	:	ALBANY
State	:	KY
Zip	:	42602-1749
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1074 VIRGINIA AVE
Second Line	:
City	:	ALBANY
State	:	KY
Zip	:	42602-1749
Country	:	US
Telephone Number	:	606-688-2534
Fax Number	:

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

Provider Enumeration Date	:	04/06/2020
Last Update Date	:	04/06/2020

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