Healthcare Provider Details

I. General information

NPI: 1780176271
Provider Name (Legal Business Name): ANTHONY M RENELLO JR. MS LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8171 E INDIAN BEND RD STE 101
SCOTTSDALE AZ
85250-4830
US

IV. Provider business mailing address

8540 E MCDOWELL RD UNIT 60
MESA AZ
85207-1431
US

V. Phone/Fax

Practice location:
  • Phone: 800-922-0094
  • Fax:
Mailing address:
  • Phone: 480-606-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC15189
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: