Provider Demographics
NPI:1982845418
Name:RENAUD, MICHELLE ANN
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANN
Last Name:RENAUD
Suffix:
Gender:F
Credentials:
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 43
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0043
Mailing Address - Country:US
Mailing Address - Phone:517-623-6260
Mailing Address - Fax:517-623-6460
Practice Address - Street 1:3493 WOODS EDGE
Practice Address - Street 2:SUITE 103
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5911
Practice Address - Country:US
Practice Address - Phone:517-886-3707
Practice Address - Fax:517-349-1973
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-12
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010615551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI800C313060OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIP40800010Medicare PIN