Healthcare Provider Details

I. General information

NPI: 1336028489
Provider Name (Legal Business Name): RENEWAL RETREAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10845 W MONTEROSA ST
PHOENIX AZ
85037-5754
US

IV. Provider business mailing address

10845 W MONTEROSA ST
PHOENIX AZ
85037-5754
US

V. Phone/Fax

Practice location:
  • Phone: 952-297-7797
  • Fax:
Mailing address:
  • Phone: 952-297-7797
  • Fax:

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 Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. PASCHA MCCORMICK
Title or Position: OWNER
Credential:
Phone: 952-297-7797