Provider Demographics
NPI:1245425354
Name:NEUROBEHAVIORAL HEALTH CLINIC
Entity Type:Organization
Organization Name:NEUROBEHAVIORAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-803-0231
Mailing Address - Street 1:419 W RIVER FRONT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6110 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4308
Practice Address - Country:US
Practice Address - Phone:414-803-0231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2478103G00000X, 103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty