Healthcare Provider Details

I. General information

NPI: 1407180284
Provider Name (Legal Business Name): RENAISSANCE THERAPY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1O WEST SQUARE LAKE RD SUITE 221
BLOOMFIELD HILLS MI
48302-0466
US

IV. Provider business mailing address

1O WEST SQUARE LAKE RD SUITE 101
BLOOMFIELD HILLS MI
48302-0466
US

V. Phone/Fax

Practice location:
  • Phone: 248-990-0140
  • Fax:
Mailing address:
  • Phone: 248-990-0140
  • Fax: 888-510-9669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401005273
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301000821
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801069906
License Number StateMI

VIII. Authorized Official

Name: DR. VLADIMIR ROBERT VANDALOV
Title or Position: OWNER
Credential: PSYD, LPC, NCC
Phone: 248-990-0140