Healthcare Provider Details

I. General information

NPI: 1033137724
Provider Name (Legal Business Name): RENEW BEHAVORIAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 LONG BEACH BLVD STE 228
LONG BEACH CA
90807-2617
US

IV. Provider business mailing address

PO BOX 20140
LONG BEACH CA
90801-3140
US

V. Phone/Fax

Practice location:
  • Phone: 562-637-3143
  • Fax: 562-637-3244
Mailing address:
  • Phone: 562-637-3143
  • Fax: 562-637-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA66124
License Number StateCA

VIII. Authorized Official

Name: LAJA I IBRAHEEM
Title or Position: MD OWNER
Credential: MD
Phone: 562-637-3143