Healthcare Provider Details

I. General information

NPI: 1063974848
Provider Name (Legal Business Name): RENEWAL WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PLYMOUTH RD STE 126
PLYMOUTH MI
48170-4080
US

IV. Provider business mailing address

409 PLYMOUTH RD STE 126
PLYMOUTH MI
48170-4080
US

V. Phone/Fax

Practice location:
  • Phone: 248-837-0303
  • Fax:
Mailing address:
  • Phone: 248-837-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE EHART
Title or Position: SOLE MEMBER / AUTHORIZED OFFICIAL
Credential: MA LLP
Phone: 248-837-0303