Healthcare Provider Details

I. General information

NPI: 1922559665
Provider Name (Legal Business Name): LIFE RENEWAL NEWTWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33634 W 8 MILE RD
FARMINGTON HILLS MI
48335-5202
US

IV. Provider business mailing address

33634 W 8 MILE RD
FARMINGTON HILLS MI
48335-5202
US

V. Phone/Fax

Practice location:
  • Phone: 248-474-2763
  • Fax: 248-476-4990
Mailing address:
  • Phone: 248-474-2763
  • Fax: 248-476-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401001490
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401001490
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6401001490
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401001490
License Number StateMI

VIII. Authorized Official

Name: DR. TIMOTHY BROE
Title or Position: DIRECTOR
Credential: PHD, MA, LPC
Phone: 248-474-2763