Healthcare Provider Details

I. General information

NPI: 1679645147
Provider Name (Legal Business Name): DANIEL RENSTROM LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16456 E C AVE
AUGUSTA MI
49012-9340
US

IV. Provider business mailing address

515 E STOCKBRIDGE AVE
KALAMAZOO MI
49001-2933
US

V. Phone/Fax

Practice location:
  • Phone: 269-888-4212
  • Fax: 269-276-5290
Mailing address:
  • Phone: 269-388-4875
  • Fax: 269-276-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801084943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: