Healthcare Provider Details

I. General information

NPI: 1861110504
Provider Name (Legal Business Name): KEISHA RENDER M.ED, CADC-DP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 CONNER ST
DETROIT MI
48213-3448
US

IV. Provider business mailing address

5555 CONNER ST STE 1038
DETROIT MI
48213-3487
US

V. Phone/Fax

Practice location:
  • Phone: 313-655-1140
  • Fax:
Mailing address:
  • Phone: 313-308-0270
  • Fax: 313-308-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: