Healthcare Provider Details

I. General information

NPI: 1316265143
Provider Name (Legal Business Name): RENEW COUNSELING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OLD LONG RIDGE RD
STAMFORD CT
06903-1112
US

IV. Provider business mailing address

8 WAKEMAN RD
FAIRFIELD CT
06824-5120
US

V. Phone/Fax

Practice location:
  • Phone: 187-784-7363
  • Fax:
Mailing address:
  • Phone: 203-255-5078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number001291
License Number StateCT

VIII. Authorized Official

Name: DR. DUANE KELLOGG
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 18778473639