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General NPI Number Information
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NPI Number | 1407491137
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Entity Type | Organization
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Legal Business Name | RENEW THERAPEUTIC SERVICES
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Dates
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Enumeration Date | 11/18/2019
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Last Update Date | 01/23/2020
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Provider Practice Location Address
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Address Line | 10336 S WESTERN AVE STE 1
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City | CHICAGO
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State | IL
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Zip | 60643-2407
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Country | US
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Telephone | 708-906-5327
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Fax | 773-304-3885
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Provider Business Mailing Address
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Address Line | 430 E 162ND ST STE 109
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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 | 708-916-5327
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Fax | 773-304-3885
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Authorized Official
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Title or Position | OWNER
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Name | MS. FELICIA MADLOCK
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Credential | LCSW
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Telephone | 708-916-5327
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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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