Provider Demographics
NPI:1609950211
Name:RENNER, MARK J (MS LMHP, CPC, LIMHP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:RENNER
Suffix:
Gender:M
Credentials:MS LMHP, CPC, LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-5004
Mailing Address - Country:US
Mailing Address - Phone:402-941-7016
Mailing Address - Fax:402-941-7018
Practice Address - Street 1:748 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5004
Practice Address - Country:US
Practice Address - Phone:402-941-7016
Practice Address - Fax:402-941-7018
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2401101Y00000X
NE1320101Y00000X
NE677101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025122100Medicaid
NE10025816100OtherMEDICAID SA