Provider Demographics
NPI:1205212453
Name:RENDERMAN, TRACY (SAC, IDP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:RENDERMAN
Suffix:
Gender:F
Credentials:SAC, IDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6445
Mailing Address - Country:US
Mailing Address - Phone:715-694-2188
Mailing Address - Fax:
Practice Address - Street 1:2611 12TH ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6445
Practice Address - Country:US
Practice Address - Phone:715-421-8869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)