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General NPI Number Information
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NPI Number | 1386940815
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Entity Type | Organization
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Legal Business Name | THE RENAISSANCE CENTER I
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 02/01/2011
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Provider Practice Location Address
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Address Line | 1337 S INDIANA PKWY
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City | CHICAGO
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State | IL
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Zip | 60605-2619
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Country | US
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Telephone | 773-671-0466
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Fax | 312-945-3750
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Provider Business Mailing Address
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Address Line | 430 E 162ND ST SUITE 492
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-2258
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Country | US
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Telephone | 773-671-0466
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Fax | 312-945-3750
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DR. JERRY L WEEMS
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Credential | PSY.D.
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Telephone | 773-671-0466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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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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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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Taxonomy #15
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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