Provider Demographics
NPI:1821354952
Name:TIRRELL, RENEA MICHELLE (LADC)
Entity Type:Individual
Prefix:
First Name:RENEA
Middle Name:MICHELLE
Last Name:TIRRELL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 LYNNRICH DR
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1032
Mailing Address - Country:US
Mailing Address - Phone:203-510-9540
Mailing Address - Fax:
Practice Address - Street 1:344 WATERTOWN RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:CT
Practice Address - Zip Code:06787-1921
Practice Address - Country:US
Practice Address - Phone:203-819-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YA0400X
CT0001272101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004123840Medicaid
CT008031626Medicaid
CT008017935Medicaid