Provider Demographics
NPI:1952027955
Name:ANDERSON, RENEE ELIZABETH
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ELIZABETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:ELIZABETH
Other - Last Name:COUTURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 ST PATRICK PL
Mailing Address - Street 2:
Mailing Address - City:PORT HENRY
Mailing Address - State:NY
Mailing Address - Zip Code:12974-1200
Mailing Address - Country:US
Mailing Address - Phone:518-546-3381
Mailing Address - Fax:518-546-3768
Practice Address - Street 1:10 ST PATRICK PL
Practice Address - Street 2:
Practice Address - City:PORT HENRY
Practice Address - State:NY
Practice Address - Zip Code:12974-1200
Practice Address - Country:US
Practice Address - Phone:518-546-3381
Practice Address - Fax:518-546-3768
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1630473221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1630473221OtherNYS EMERGENCY COVID-19