Healthcare Provider Details

I. General information

NPI: 1811861255
Provider Name (Legal Business Name): RENEST (I) RISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RING RD STE 155
ELIZABETHTOWN KY
42701-8790
US

IV. Provider business mailing address

400 RING RD STE 155
ELIZABETHTOWN KY
42701-8790
US

V. Phone/Fax

Practice location:
  • Phone: 844-473-6378
  • Fax: 270-246-9950
Mailing address:
  • Phone: 844-473-6378
  • Fax: 270-246-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: THERESA WADDELL
Title or Position: ADMINISTRATIVE OFFICER
Credential: MA, MFTA, CADC
Phone: 844-473-6378