Provider Demographics
NPI:1346640133
Name:RENNIS, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:RENNIS
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 1:226 LINDA AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2018
Mailing Address - Country:US
Mailing Address - Phone:914-773-6766
Mailing Address - Fax:914-773-7698
Practice Address - Street 1:226 LINDA AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2018
Practice Address - Country:US
Practice Address - Phone:914-773-6766
Practice Address - Fax:914-773-7698
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker