Healthcare Provider Details

I. General information

NPI: 1275058745
Provider Name (Legal Business Name): THE RENFREW CENTER OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REVERE DR, SUITE 100
NORTHBROOK IL
60062
US

IV. Provider business mailing address

5 REVERE DR STE 100
NORTHBROOK IL
60062-1567
US

V. Phone/Fax

Practice location:
  • Phone: 847-291-6805
  • Fax: 847-291-6815
Mailing address:
  • Phone: 847-291-6805
  • Fax: 847-291-6815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.012613
License Number StateIL

VIII. Authorized Official

Name: MELISSA MARTIN
Title or Position: PRIMARY THERAPIST
Credential: LPC
Phone: 847-291-6805