Provider Demographics
NPI:1770596199
Name:RENNER, LESLIE L (LCSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:L
Last Name:RENNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25166 MARION AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4017
Mailing Address - Country:US
Mailing Address - Phone:941-467-6367
Mailing Address - Fax:
Practice Address - Street 1:25166 MARION AVE
Practice Address - Street 2:STE 112
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4017
Practice Address - Country:US
Practice Address - Phone:941-467-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW6138101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1902OtherBLUE CROSS
FLE48674Medicare ID - Type UnspecifiedMEDICARE#