Provider Demographics
NPI:1790923670
Name:DEREZIN, RENA SUSAN (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:SUSAN
Last Name:DEREZIN
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:SILVERTHORNE
Mailing Address - State:CO
Mailing Address - Zip Code:80498-0139
Mailing Address - Country:US
Mailing Address - Phone:303-807-2750
Mailing Address - Fax:
Practice Address - Street 1:135 CLEAR CREEK STREET
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:CO
Practice Address - Zip Code:80422-0418
Practice Address - Country:US
Practice Address - Phone:303-807-2750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional