Provider Demographics
NPI:1801594528
Name:RENARD, THEODORE JOHNATHAN (LADC-I)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHNATHAN
Last Name:RENARD
Suffix:
Gender:M
Credentials:LADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PORTLAND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3271
Mailing Address - Country:US
Mailing Address - Phone:617-680-4094
Mailing Address - Fax:
Practice Address - Street 1:118 PLEASANT ST STE 22B
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2344
Practice Address - Country:US
Practice Address - Phone:617-680-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)