Provider Demographics
NPI:1033835376
Name:RENCKERT, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:RENCKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6198 STATE ROUTE 21
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:556 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1105
Practice Address - Country:US
Practice Address - Phone:585-442-8422
Practice Address - Fax:585-442-8494
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37529-T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid