=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396106167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENEWED PURPOSE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 03/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15210 HIGHWAY 3 SUITE 105B
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-204-9299
-----------------------------------------------------
Fax | 281-204-9114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15210 HIGHWAY 3 SUITE 105B
-----------------------------------------------------
City | WEBSTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77598-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-204-9299
-----------------------------------------------------
Fax | 281-204-9114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAING MEMBER
-----------------------------------------------------
Name | AUDREY ROSE MORRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-204-9299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 33383
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------