Provider Demographics
NPI:1083897383
Name:RENNICKE, COURTNEY M (PHD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:RENNICKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 E 57TH ST
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2707
Mailing Address - Country:US
Mailing Address - Phone:212-308-2440
Mailing Address - Fax:
Practice Address - Street 1:136 E 57TH ST
Practice Address - Street 2:SUITE 1101
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2707
Practice Address - Country:US
Practice Address - Phone:212-308-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017456103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent