Provider Demographics
NPI:1447877022
Name:SANDBERG, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15762 VISCOUNT CIR
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33981-3339
Mailing Address - Country:US
Mailing Address - Phone:770-510-8251
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician