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General NPI Number Information
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NPI Number | 1093255242
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Entity Type | Individual
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Provider Name | CHERYL ANN RENZULLI MA, LAT
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Gender | Female
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Dates
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Enumeration Date | 03/06/2017
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Last Update Date | 03/06/2017
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Provider Practice Location Address
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Address Line | 1115 MAPLE WAY SUITE C
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City | JACKSON
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State | WY
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Zip | 83001-8567
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Country | US
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Telephone | 307-699-0807
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Fax | 307-733-7339
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Provider Business Mailing Address
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Address Line | PO BOX 9615
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City | JACKSON
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State | WY
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Zip | 83002-9615
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Country | US
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Telephone | 307-699-0807
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Fax | 307-733-7339
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LAT #324
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License Number State | WY
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