Provider Demographics
NPI:1902460819
Name:RENFROE, REBECCA JO
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:RENFROE
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 1:109 N FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4205
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4205
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8014104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker