Healthcare Provider Details

I. General information

NPI: 1508156266
Provider Name (Legal Business Name): RENASCENCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 S GLEBE RD STE 103
ARLINGTON VA
22204-1671
US

IV. Provider business mailing address

46 S GLEBE RD STE 103
ARLINGTON VA
22204-1671
US

V. Phone/Fax

Practice location:
  • Phone: 703-521-6004
  • Fax: 703-521-6342
Mailing address:
  • Phone: 703-521-6004
  • Fax: 703-521-6342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: NANCY GRAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 703-521-6004