Provider Demographics
NPI:1669619904
Name:RENNER, MICHAEL L (LIMHP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:RENNER
Suffix:
Gender:M
Credentials:LIMHP
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 326
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:NE
Mailing Address - Zip Code:68333-0326
Mailing Address - Country:US
Mailing Address - Phone:402-826-2000
Mailing Address - Fax:402-826-2655
Practice Address - Street 1:1212 IVY AVE
Practice Address - Street 2:STE 2
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-2301
Practice Address - Country:US
Practice Address - Phone:402-826-2000
Practice Address - Fax:402-826-2655
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1020101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47052851582Medicaid
NE10025208300Medicaid
NE47052851509Medicaid
NE47052851507Medicaid
NE47052851505Medicaid
NE10025207900Medicaid