Provider Demographics
NPI:1750527222
Name:RENNIE, MARCIA JELLA' (PHD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:JELLA'
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 1:825 ZION ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2922
Mailing Address - Country:US
Mailing Address - Phone:530-265-2199
Mailing Address - Fax:530-265-2619
Practice Address - Street 1:825 ZION ST
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2922
Practice Address - Country:US
Practice Address - Phone:530-265-2199
Practice Address - Fax:530-265-2619
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22214103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent