Healthcare Provider Details

I. General information

NPI: 1003993049
Provider Name (Legal Business Name): PEGGY RENNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 W CHARLESTON BLVD STE 2-623
LAS VEGAS NV
89117-7528
US

IV. Provider business mailing address

9811 W CHARLESTON BLVD STE 2-623
LAS VEGAS NV
89117-7528
US

V. Phone/Fax

Practice location:
  • Phone: 702-478-8400
  • Fax: 702-478-8500
Mailing address:
  • Phone: 702-478-8400
  • Fax: 702-478-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0517
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY0517
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: