Provider Demographics
NPI:1548275332
Name:RENVILLE, MAURINE R (LISW)
Entity type:Individual
Prefix:MS
First Name:MAURINE
Middle Name:R
Last Name:RENVILLE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LOMAS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1234
Mailing Address - Country:US
Mailing Address - Phone:505-766-5363
Mailing Address - Fax:
Practice Address - Street 1:1330 LOMAS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1234
Practice Address - Country:US
Practice Address - Phone:505-766-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2008-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-39851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201008219OtherPRESBYTERIAN HEALTH CARE
NMNM101564Medicaid
NM79994Medicaid
NMNM101564Medicaid