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General NPI Number Information
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NPI Number | 1801594528
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Entity Type | Individual
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Provider Name | THEODORE JOHNATHAN RENARD LADC-I
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Gender | Male
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Dates
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Enumeration Date | 02/21/2023
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Last Update Date | 02/21/2023
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Provider Practice Location Address
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Address Line | 118 PLEASANT ST STE 22B
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City | MARBLEHEAD
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State | MA
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Zip | 01945-2344
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Country | US
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Telephone | 617-680-4094
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Fax |
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Provider Business Mailing Address
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Address Line | 21 PORTLAND ST APT 2
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City | LYNN
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State | MA
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Zip | 01902-3271
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Country | US
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Telephone | 617-680-4094
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 16000
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License Number State | MA
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