Provider Demographics
NPI:1740711803
Name:RENZAGLIA-WEIR, MARY JO
Entity type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:
Last Name:RENZAGLIA-WEIR
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 1:988 N ILLINOIS ROUTE 3
Mailing Address - Street 2:PO BOX 146
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1000
Mailing Address - Country:US
Mailing Address - Phone:618-939-4444
Mailing Address - Fax:
Practice Address - Street 1:988 N ILLINOIS ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1000
Practice Address - Country:US
Practice Address - Phone:618-939-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1020845103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370968305Medicaid