Provider Demographics
NPI:1720330897
Name:DEVOLLD, RENAE
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:DEVOLLD
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 1:13748 VALERA WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6372
Mailing Address - Country:US
Mailing Address - Phone:760-243-6772
Mailing Address - Fax:
Practice Address - Street 1:13748 VALERA WAY
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-6372
Practice Address - Country:US
Practice Address - Phone:760-243-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health