Provider Demographics
NPI: | 1114613528 |
---|---|
Name: | RENTERIA, MICHELLE |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHELLE |
Middle Name: | |
Last Name: | RENTERIA |
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: | 879 W 190TH ST STE 300 |
Mailing Address - Street 2: | |
Mailing Address - City: | GARDENA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90248-4223 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-850-0115 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 879 W 190TH ST STE 300 |
Practice Address - Street 2: | |
Practice Address - City: | GARDENA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90248-4223 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-912-8258 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2023-04-18 |
Last Update Date: | 2024-03-20 |
Deactivation Date: | 2024-03-11 |
Deactivation Code: | |
Reactivation Date: | 2024-03-19 |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
CA | 145836 | 106H00000X |
CA | 16491 | 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |