Provider Demographics
NPI:1912279910
Name:RENNER, KATHRYN ELISE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELISE
Last Name:RENNER
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 1:1201 25TH ST S
Mailing Address - Street 2:PO BOX 9859
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:
Practice Address - Street 1:224 4TH ST NW STE 5
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2960
Practice Address - Country:US
Practice Address - Phone:701-662-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND704-12-1-11A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health