Provider Demographics
NPI:1275818296
Name:RENNEBOHM, ROBERT
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:RENNEBOHM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CENTER
Mailing Address - Street 2:SUITE 456J
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-921-4000
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CENTER
Practice Address - Street 2:SUITE 456J
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-921-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1166081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical