Healthcare Provider Details

I. General information

NPI: 1598508095
Provider Name (Legal Business Name): RENEWED LIFE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 DAUPHIN ST STE 319
MOBILE AL
36602-3271
US

IV. Provider business mailing address

9029 DAWES OAK DR
THEODORE AL
36582-9654
US

V. Phone/Fax

Practice location:
  • Phone: 251-376-4249
  • Fax:
Mailing address:
  • Phone: 251-376-4249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. TRACY RENEE GIBSON
Title or Position: OWNER/COUNSELOR
Credential: MS, ALC
Phone: 251-376-4249