Provider Demographics
NPI:1558643502
Name:RENSHAW, KEITH D (PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:RENSHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4400 UNIVERSITY DR
Mailing Address - Street 2:MSN3F5 DEPARTMENT OF PSYCHOLOGY
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4444
Mailing Address - Country:US
Mailing Address - Phone:703-993-5128
Mailing Address - Fax:703-993-1359
Practice Address - Street 1:10340 DEMOCRACY LN
Practice Address - Street 2:STE 202
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2518
Practice Address - Country:US
Practice Address - Phone:703-993-5128
Practice Address - Fax:703-993-1359
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0810004355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical