Healthcare Provider Details

I. General information

NPI: 1194554527
Provider Name (Legal Business Name): RENAE DELUCIA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

1509 N JACKSON ST APT 303
MILWAUKEE WI
53202-3082
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 630-336-3302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number5167-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: