Healthcare Provider Details

I. General information

NPI: 1114893161
Provider Name (Legal Business Name): RENOVA THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13506 ROBERT WALKER DR
DAVIDSON NC
28036-6008
US

IV. Provider business mailing address

13506 ROBERT WALKER DR
DAVIDSON NC
28036-6008
US

V. Phone/Fax

Practice location:
  • Phone: 704-818-8169
  • Fax:
Mailing address:
  • Phone: 704-818-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NATALIE C FOROUZAD
Title or Position: OWNER
Credential: LCSW
Phone: 704-818-8169