Provider Demographics
NPI:1932178803
Name:RENNICK, PETER JOHN (MS)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:RENNICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W LA JOLLA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4805
Mailing Address - Country:US
Mailing Address - Phone:602-306-0110
Mailing Address - Fax:480-921-0307
Practice Address - Street 1:2101 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1879
Practice Address - Country:US
Practice Address - Phone:602-306-0110
Practice Address - Fax:480-921-0307
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health