Provider Demographics
NPI:1679645147
Name:RENSTROM, DANIEL (LMSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RENSTROM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E STOCKBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2933
Mailing Address - Country:US
Mailing Address - Phone:269-388-4875
Mailing Address - Fax:269-276-5290
Practice Address - Street 1:16456 E C AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:MI
Practice Address - Zip Code:49012-9340
Practice Address - Country:US
Practice Address - Phone:269-888-4212
Practice Address - Fax:269-276-5290
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010849431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical