Provider Demographics
NPI:1336193341
Name:RENNIE, KIMBERLY M (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:RENNIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 FANNIN ST STE 824
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:713-500-7840
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 824
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:713-500-7840
Practice Address - Fax:713-486-0860
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2478-57103G00000X, 103TH0004X
WI2478103TC2200X
TX36245103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
007906261UOtherHUMANA
WI39143300Medicaid
0021373601Medicare ID - Type Unspecified