Provider Demographics
NPI:1093490591
Name:RENFROW, MICHELLE L TUCKER
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L TUCKER
Last Name:RENFROW
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 1:3502 GREEN FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1843
Mailing Address - Country:US
Mailing Address - Phone:832-607-3673
Mailing Address - Fax:
Practice Address - Street 1:3502 GREEN FIELDS DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-1843
Practice Address - Country:US
Practice Address - Phone:832-607-3673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20169101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health