Provider Demographics
NPI:1033521067
Name:ROEL, RENZO (MS)
Entity Type:Individual
Prefix:MR
First Name:RENZO
Middle Name:
Last Name:ROEL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 S KINNELOA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3853
Mailing Address - Country:US
Mailing Address - Phone:626-327-4565
Mailing Address - Fax:
Practice Address - Street 1:36 S KINNELOA AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3853
Practice Address - Country:US
Practice Address - Phone:626-327-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF80477106H00000X
106H00000X
CA80477101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist