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General NPI Number Information
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NPI Number | 1013723725
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Entity Type | Organization
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Legal Business Name | RENEGADE COUNSELING
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Dates
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Enumeration Date | 12/06/2024
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 5303 OLD COUNTY RD 611
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City | KINGSLEY
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State | MI
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Zip | 49649-9246
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Country | US
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Telephone | 231-429-8396
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Fax |
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Provider Business Mailing Address
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Address Line | 5303 OLD COUNTY RD 611
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City | KINGSLEY
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State | MI
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Zip | 49649-9246
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH COUNSELOR
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Name | SHEA STOKES
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Credential | LPC
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Telephone | 231-429-8396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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