Provider Demographics
NPI:1609168392
Name:SANSOM, RENEE NICOLE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:SANSOM
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 1:414 TIMBERWIND RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3109
Mailing Address - Country:US
Mailing Address - Phone:405-315-1364
Mailing Address - Fax:
Practice Address - Street 1:414 TIMBERWIND RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3109
Practice Address - Country:US
Practice Address - Phone:405-315-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health