Healthcare Provider Details

I. General information

NPI: 1386902765
Provider Name (Legal Business Name): RENAISSANCE RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 N GILBERT RD SUITE B140
GILBERT AZ
85234-4591
US

IV. Provider business mailing address

459 N GILBERT RD SUITE B140
GILBERT AZ
85234-4591
US

V. Phone/Fax

Practice location:
  • Phone: 480-632-1345
  • Fax: 480-632-1354
Mailing address:
  • Phone: 480-632-1345
  • Fax: 480-632-1354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN RALLIS BROWN
Title or Position: OWNER
Credential: L.C.S.W.
Phone: 480-632-1345