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General NPI Number Information
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NPI Number | 1407439383
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Entity Type | Organization
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Legal Business Name | RENAISSANCE MENTAL LLC
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Dates
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Enumeration Date | 04/29/2021
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Last Update Date | 06/06/2024
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Provider Practice Location Address
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Address Line | 18501 PINES BLVD STE 374-375
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City | PEMBROKE PINES
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State | FL
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Zip | 33029-1414
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Country | US
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Telephone | 786-630-8663
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Fax |
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Provider Business Mailing Address
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Address Line | 18501 PINES BLVD STE 374-375
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City | PEMBROKE PINES
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State | FL
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Zip | 33029-1414
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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 | ADMINISTRATOR
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Name | MELISSA DE LA CRUZ DE LA IGLESIA
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Credential | CBHCM
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Telephone | 786-630-8663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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