Basic Information
| Provider Information | |||||||||
| NPI: | 1548508708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENDER | ||||||||
| FirstName: | NATHANIAL | ||||||||
| MiddleName: | ODELL | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801 VETERANS DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202521670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21907 64TH AVE W STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNTLAKE TERRACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980436200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256407009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2013 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW60284806 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |