Provider Demographics
NPI:1235406224
Name:TRAYLOR, RENESHA (FACILITATOR)
Entity Type:Individual
Prefix:MS
First Name:RENESHA
Middle Name:
Last Name:TRAYLOR
Suffix:
Gender:F
Credentials:FACILITATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1851
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-0851
Mailing Address - Country:US
Mailing Address - Phone:323-419-6859
Mailing Address - Fax:
Practice Address - Street 1:652 E MANCHESTER BLVD
Practice Address - Street 2:200A
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1910
Practice Address - Country:US
Practice Address - Phone:323-777-4893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health