Provider Demographics
NPI:1396195087
Name:RENICH, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RENICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 S MERIDIAN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7516
Mailing Address - Country:US
Mailing Address - Phone:253-446-3202
Mailing Address - Fax:
Practice Address - Street 1:1706 S MERIDIAN
Practice Address - Street 2:SUITE 120
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7516
Practice Address - Country:US
Practice Address - Phone:253-446-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60604653106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist