Healthcare Provider Details

I. General information

NPI: 1942165048
Provider Name (Legal Business Name): RENEW 360 SUPPORT SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 LUCENA ST
CHARLOTTE NC
28206-2109
US

IV. Provider business mailing address

2631 LUCENA ST
CHARLOTTE NC
28206-2109
US

V. Phone/Fax

Practice location:
  • Phone: 704-277-3538
  • Fax: 704-277-3538
Mailing address:
  • Phone: 704-277-3538
  • Fax: 704-277-3538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: LAGINA MCCLINTON
Title or Position: OWNER
Credential:
Phone: 704-277-3538