Healthcare Provider Details

I. General information

NPI: 1134252836
Provider Name (Legal Business Name): MRS. RENEA LYNN HEROLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22833 N 71ST AVE
GLENDALE AZ
85310-5201
US

IV. Provider business mailing address

6612 W BROOKHART WAY
PHOENIX AZ
85085-7402
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-3319
  • Fax:
Mailing address:
  • Phone: 623-388-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: