Provider Demographics
NPI:1164604690
Name:RENNER, THERESA MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:RENNER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2413
Mailing Address - Country:US
Mailing Address - Phone:307-689-0791
Mailing Address - Fax:
Practice Address - Street 1:208 EDGEMONT BLVD
Practice Address - Street 2:PLACHY HALL - ATHLETIC TRAINING
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81102-0001
Practice Address - Country:US
Practice Address - Phone:719-587-7431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer