Provider Demographics
NPI:1720490030
Name:RENN, PAUL IV
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RENN
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 HAVERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-1401
Mailing Address - Country:US
Mailing Address - Phone:215-471-2761
Mailing Address - Fax:
Practice Address - Street 1:2310 CHRISTOPHER COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-4206
Practice Address - Country:US
Practice Address - Phone:215-867-7098
Practice Address - Fax:267-288-0389
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW019392101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional