Healthcare Provider Details

I. General information

NPI: 1336754050
Provider Name (Legal Business Name): LIFE RENEW COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 WALNUT GROVE RD
MEMPHIS TN
38111-2719
US

IV. Provider business mailing address

652 SPOTTSWOOD MANOR DR
MEMPHIS TN
38111-4329
US

V. Phone/Fax

Practice location:
  • Phone: 901-647-6160
  • Fax:
Mailing address:
  • Phone: 901-647-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERA BROWNLEE
Title or Position: OWNER/THERAPIST
Credential: LPC-MHSP
Phone: 901-647-6160