Provider Demographics
NPI:1760501506
Name:GEARHART, RENEE L (MED NCC)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:GEARHART
Suffix:
Gender:F
Credentials:MED NCC
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:L
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13528 S BRENTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-9246
Mailing Address - Country:US
Mailing Address - Phone:928-446-9903
Mailing Address - Fax:
Practice Address - Street 1:1453 N. MAIN STREET
Practice Address - Street 2:SUITE F
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ838162OtherAHCCCS