Provider Demographics
NPI:1942858881
Name:BIRT, RENITA ANN (MS, QMHP)
Entity Type:Individual
Prefix:MISS
First Name:RENITA
Middle Name:ANN
Last Name:BIRT
Suffix:
Gender:F
Credentials:MS, QMHP
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 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:
Practice Address - Street 1:656 STERLING CT
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-8279
Practice Address - Country:US
Practice Address - Phone:708-972-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No347C00000XTransportation ServicesPrivate Vehicle
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid