Healthcare Provider Details

I. General information

NPI: 1962831735
Provider Name (Legal Business Name): THE LOIS RENFRO FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 M ST NE
AUBURN WA
98002-4430
US

IV. Provider business mailing address

105 M ST NE
AUBURN WA
98002-4430
US

V. Phone/Fax

Practice location:
  • Phone: 253-333-2328
  • Fax: 253-333-5068
Mailing address:
  • Phone: 253-333-2328
  • Fax: 253-333-5068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number17159400
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number17159400
License Number StateWA

VIII. Authorized Official

Name: GEORGE FREDERICK BRUMMELL
Title or Position: COUNSELOR
Credential: CDP LMHCA
Phone: 253-347-0428