Provider Demographics
NPI:1659931756
Name:RENFRO, LYDIA CHANEL
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CHANEL
Last Name:RENFRO
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 1:2590 WELTON ST APT 812
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3787
Mailing Address - Country:US
Mailing Address - Phone:928-587-9198
Mailing Address - Fax:628-288-7758
Practice Address - Street 1:2590 WELTON ST APT 812
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-3787
Practice Address - Country:US
Practice Address - Phone:928-587-9198
Practice Address - Fax:628-288-7758
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-19-35827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst