Provider Demographics
NPI:1790314938
Name:RENNER, KIM LORI (BCBA, LLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LORI
Last Name:RENNER
Suffix:
Gender:F
Credentials:BCBA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6607 SEAGATE AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5817
Mailing Address - Country:US
Mailing Address - Phone:419-351-1723
Mailing Address - Fax:
Practice Address - Street 1:6976 PROFESSIONAL PKWY E
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8414
Practice Address - Country:US
Practice Address - Phone:941-308-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOBA.35103K00000X
MI6301011821103T00000X
OH1-05-2410103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist