Provider Demographics
NPI:1093255242
Name:RENZULLI, CHERYL ANN (MA, LAT)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:ANN
Last Name:RENZULLI
Suffix:
Gender:F
Credentials:MA, LAT
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 9615
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9615
Mailing Address - Country:US
Mailing Address - Phone:307-699-0807
Mailing Address - Fax:307-733-7339
Practice Address - Street 1:1115 MAPLE WAY
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8567
Practice Address - Country:US
Practice Address - Phone:307-699-0807
Practice Address - Fax:307-733-7339
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT #324101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)