Healthcare Provider Details

I. General information

NPI: 1114613528
Provider Name (Legal Business Name): MICHELLE AILEEN RENTERIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date: 03/11/2024
Reactivation Date: 03/19/2024

III. Provider practice location address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

IV. Provider business mailing address

PO BOX 42026
LOS ANGELES CA
90042-0026
US

V. Phone/Fax

Practice location:
  • Phone: 562-532-9234
  • Fax:
Mailing address:
  • Phone: 562-532-9234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT164816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: