Healthcare Provider Details

I. General information

NPI: 1215507454
Provider Name (Legal Business Name): MIKAELA RENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 BLISS WAY
KISSIMMEE FL
34747
US

IV. Provider business mailing address

2705 WOLCOTT LN
KISSIMMEE FL
34747-1817
US

V. Phone/Fax

Practice location:
  • Phone: 352-363-5066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6163
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH26285
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: