Provider Demographics
NPI:1730258898
Name:MCARDLE, RENEE A SR (PSYD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:MCARDLE
Suffix:SR
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4873 MANHATTAN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2265
Mailing Address - Country:US
Mailing Address - Phone:815-965-1817
Mailing Address - Fax:815-965-9574
Practice Address - Street 1:4873 MANHATTAN DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2265
Practice Address - Country:US
Practice Address - Phone:815-965-1817
Practice Address - Fax:815-965-9574
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364361454OtherTAX ID
IL216550Medicare ID - Type Unspecified