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General NPI Number Information
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NPI Number | 1316538663
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Entity Type | Organization
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Legal Business Name | RENEW WELLNESS LLC
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Dates
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Enumeration Date | 01/29/2021
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Last Update Date | 02/17/2021
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Provider Practice Location Address
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Address Line | 1281 E IRON EAGLE DR
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City | EAGLE
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State | ID
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Zip | 83616-6599
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Country | US
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Telephone | 208-912-4011
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Fax |
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Provider Business Mailing Address
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Address Line | 5650 N DALSPRING AVE
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City | BOISE
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State | ID
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Zip | 83713-1315
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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 | OWNER
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Name | MALISA WILLIAMS
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Credential | LCSW
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Telephone | 208-912-4011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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