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General NPI Number Information
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NPI Number | 1245425354
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Entity Type | Organization
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Legal Business Name | NEUROBEHAVIORAL HEALTH CLINIC
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 6110 N PORT WASHINGTON RD
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City | GLENDALE
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State | WI
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Zip | 53217-4308
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Country | US
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Telephone | 414-803-0231
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Fax |
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Provider Business Mailing Address
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Address Line | 419 W RIVER FRONT DR
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City | GLENDALE
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State | WI
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Zip | 53217-4460
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KIMBERLY M RENNIE
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Credential | PHD
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Telephone | 414-803-0231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2478
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 2478
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 2478
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License Number State | WI
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