Provider Demographics
NPI:1841662335
Name:RENWICK, DONNA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:RENWICK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 AMERICAS WAY
Mailing Address - Street 2:PMB 5155
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-7600
Mailing Address - Country:US
Mailing Address - Phone:916-251-6729
Mailing Address - Fax:
Practice Address - Street 1:514 AMERICAS WAY
Practice Address - Street 2:PMB 5155
Practice Address - City:BOX ELDER
Practice Address - State:SD
Practice Address - Zip Code:57719-7600
Practice Address - Country:US
Practice Address - Phone:916-251-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60595952235Z00000X
CASD11384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist