Healthcare Provider Details

I. General information

NPI: 1790726214
Provider Name (Legal Business Name): JOHN LOUIS RENZULLI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 SHERMAN HILL RD STE A202
WOODBURY CT
06798-3648
US

IV. Provider business mailing address

156 STILL HILL RD
BETHLEHEM CT
06751-1010
US

V. Phone/Fax

Practice location:
  • Phone: 203-819-3680
  • Fax:
Mailing address:
  • Phone: 203-819-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: