Provider Demographics
NPI:1861072530
Name:RENFROW, MARIAH (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:RENFROW
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 BERNARD RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62893-1344
Mailing Address - Country:US
Mailing Address - Phone:618-339-9848
Mailing Address - Fax:
Practice Address - Street 1:3422 BERNARD RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILL
Practice Address - State:IL
Practice Address - Zip Code:62893-1344
Practice Address - Country:US
Practice Address - Phone:618-339-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician