Healthcare Provider Details

I. General information

NPI: 1932178803
Provider Name (Legal Business Name): PETER JOHN RENNICK M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E BROADWAY RD
TEMPE AZ
85282-1879
US

IV. Provider business mailing address

325 W LA JOLLA DR
TEMPE AZ
85282-4805
US

V. Phone/Fax

Practice location:
  • Phone: 602-306-0110
  • Fax: 480-921-0307
Mailing address:
  • Phone: 602-306-0110
  • Fax: 480-921-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-1067
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: