Provider Demographics
NPI:1326664038
Name:RENZAGLIA, KATRINA PARKS (BCBA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:PARKS
Last Name:RENZAGLIA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 HARRIS LN
Mailing Address - Street 2:
Mailing Address - City:ALTO PASS
Mailing Address - State:IL
Mailing Address - Zip Code:62905-1023
Mailing Address - Country:US
Mailing Address - Phone:618-521-5049
Mailing Address - Fax:
Practice Address - Street 1:87 HARRIS LN
Practice Address - Street 2:
Practice Address - City:ALTO PASS
Practice Address - State:IL
Practice Address - Zip Code:62905-1023
Practice Address - Country:US
Practice Address - Phone:618-521-5049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-13-13542103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst