MEDICARE: MRS. RENNE DVORAK BAINVOLL PHD

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	PSY12846	CA

General Provider Information

NPI Number	:	1417059098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RENNE DVORAK BAINVOLL PHD

Provider Business Mailing Address
First Line	:	6666 DREXEL AVE.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4209
Country	:	US
Telephone Number	:	310-227-8582
Fax Number	:	310-412-9557

Provider Business Practice Location Address
First Line	:	6666 DREXEL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4209
Country	:	US
Telephone Number	:	310-227-8582
Fax Number	:	310-412-9557

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	02/22/2012

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