Provider Demographics
NPI:1245652585
Name:RENAE, NICOLE (MFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RENAE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-2935
Mailing Address - Country:US
Mailing Address - Phone:707-347-9349
Mailing Address - Fax:
Practice Address - Street 1:7 4TH ST
Practice Address - Street 2:SUITE 49
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3043
Practice Address - Country:US
Practice Address - Phone:707-347-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC 654101YM0800X
CA45457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health