Provider Demographics
NPI:1114620994
Name:RENVILLE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RENVILLE
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 1:1534 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3950
Mailing Address - Country:US
Mailing Address - Phone:307-251-9408
Mailing Address - Fax:
Practice Address - Street 1:1534 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3950
Practice Address - Country:US
Practice Address - Phone:307-251-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health