Basic Information
| Provider Information | |||||||||
| NPI: | 1114449063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENNAKER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 E COLLEGE DR UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036172300 | ||||||||
| FaxNumber: | 3036172365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 E 3RD AVE UNIT B-5 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143150897 | ||||||||
| FaxNumber: | 3036172365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.