Provider Demographics
NPI:1023180312
Name:RENJILIAN, DAVID (PH,D)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:RENJILIAN
Suffix:
Gender:M
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-0265
Mailing Address - Country:US
Mailing Address - Phone:570-586-7245
Mailing Address - Fax:570-586-1818
Practice Address - Street 1:421 S STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1684
Practice Address - Country:US
Practice Address - Phone:570-586-7245
Practice Address - Fax:570-586-1818
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006294L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARE431684Medicare ID - Type Unspecified