Provider Demographics
NPI:1558891267
Name:DWORNITSKI, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:DWORNITSKI
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 1:3502 SCOTTS LN STE 1911B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1561
Mailing Address - Country:US
Mailing Address - Phone:267-497-3171
Mailing Address - Fax:
Practice Address - Street 1:3502 SCOTTS LN STE 1911B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1561
Practice Address - Country:US
Practice Address - Phone:267-497-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
101YP2500X
PAPC011465101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health