Provider Demographics
NPI:1700230190
Name:RENAUD, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:RENAUD
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 1:3513 ELIZABETH LAKE RD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3075
Mailing Address - Country:US
Mailing Address - Phone:734-925-0512
Mailing Address - Fax:
Practice Address - Street 1:3513 ELIZABETH LAKE RD
Practice Address - Street 2:SUITE 218
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3075
Practice Address - Country:US
Practice Address - Phone:734-925-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist