Provider Demographics
NPI:1518596055
Name:RENEAU, STEPHANIE AMBER
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:AMBER
Last Name:RENEAU
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 1:1074 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:KY
Mailing Address - Zip Code:42602-1749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1074 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1749
Practice Address - Country:US
Practice Address - Phone:606-688-2534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY133771225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist