Healthcare Provider Details

I. General information

NPI: 1174122170
Provider Name (Legal Business Name): RENEWED VISION COUNSELING AND DEVELOPMENTAL DISABILITY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 02/26/2025
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 S. 133RD ST SUITE 106
OMAHA NE
68137-1133
US

IV. Provider business mailing address

4642 S. 132ND ST
OMAHA NE
68137-1764
US

V. Phone/Fax

Practice location:
  • Phone: 402-275-6413
  • Fax:
Mailing address:
  • Phone: 531-876-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MARSHALL
Title or Position: OWNER
Credential: PLMHP
Phone: 531-876-7455