Provider Demographics
NPI:1851610380
Name:RENFRO, DARRELL L (MED, LPC)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:L
Last Name:RENFRO
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 GEORGIA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2283
Mailing Address - Country:US
Mailing Address - Phone:504-339-4801
Mailing Address - Fax:
Practice Address - Street 1:3715 WILLIAMS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3066
Practice Address - Country:US
Practice Address - Phone:504-339-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3439101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101Y00000XMedicaid