Provider Demographics
NPI:1619513942
Name:RENTERIA', MANDY MICHELLE (MA)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MICHELLE
Last Name:RENTERIA'
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5848 GUILFORD PL
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6669
Mailing Address - Country:US
Mailing Address - Phone:843-816-1815
Mailing Address - Fax:
Practice Address - Street 1:5848 GUILFORD PL
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6669
Practice Address - Country:US
Practice Address - Phone:843-816-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional