Provider Demographics
NPI:1295779882
Name:ANDERSON, RENATA
Entity type:Individual
Prefix:MRS
First Name:RENATA
Middle Name:
Last Name:ANDERSON
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 1:2237 SW COURT AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-1896
Mailing Address - Country:US
Mailing Address - Phone:541-276-5053
Mailing Address - Fax:541-276-5112
Practice Address - Street 1:2237 SW COURT AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-1896
Practice Address - Country:US
Practice Address - Phone:541-276-5053
Practice Address - Fax:541-276-5112
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-027200231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR102368Medicaid
OR0000VGBGKMedicare ID - Type Unspecified