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General NPI Number Information
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NPI Number | 1134607898
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Entity Type | Organization
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Legal Business Name | RENEW PSYCHIATRY SERVICES
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Dates
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Enumeration Date | 08/03/2018
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 177 ELECTRIC RD
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City | SALEM
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State | VA
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Zip | 24153
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Country | US
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Telephone | 678-900-0308
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Fax | 540-204-4097
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Provider Business Mailing Address
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Address Line | 5715 GLEN HAVEN DR
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City | ROANOKE
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State | VA
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Zip | 24019-4064
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Country | US
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Telephone | 678-900-0308
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Fax | 540-204-4097
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Authorized Official
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Title or Position | OWNER
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Name | MICHIE ARMELL BOLDEN
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Credential | PMHNP-BC
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Telephone | 678-900-0308
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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