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General NPI Number Information
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NPI Number | 1073096863
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Entity Type | Individual
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Provider Name | TODD MASON RENEGAR LCSW
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Gender | Male
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Dates
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Enumeration Date | 09/08/2018
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Last Update Date | 09/21/2022
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Provider Practice Location Address
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Address Line | 2495 SHREVEPORT HWY
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City | PINEVILLE
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State | LA
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Zip | 71360-4044
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Country | US
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Telephone | 318-473-0010
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Fax |
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Provider Business Mailing Address
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Address Line | 4024 MAYFLOWER BLVD
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City | ALEXANDRIA
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State | LA
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Zip | 71303-2913
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Country | US
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Telephone | 646-258-3479
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0866174-1
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License Number State | NY
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