MEDICARE: THE RENO TRUST DATED NOVEMBER 8, 2007

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1033830781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE RENO TRUST DATED NOVEMBER 8, 2007

Provider Business Mailing Address
First Line	:	1741 COLBY AVE APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4189
Country	:	US
Telephone Number	:	310-774-6104
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 COLBY AVE APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-4189
Country	:	US
Telephone Number	:	310-774-6104
Fax Number	:

Authorized Official
Title or Position	:	TRUSTOR
Name	:	DR. ROCHELLE MARIE RENO
Credential	:	PH.D.
Telephone Number	:	310-774-6104

Provider Enumeration Date	:	09/09/2022
Last Update Date	:	09/09/2022

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