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General NPI Number Information
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NPI Number | 1689684102
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Entity Type | Organization
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Legal Business Name | RENAISSANCE COUNSELING CENTER
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11070 DAVID ST
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City | GULFPORT
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State | MS
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Zip | 39503-3481
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Country | US
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Telephone | 228-832-9191
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Fax | 228-832-9150
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Provider Business Mailing Address
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Address Line | 11070 DAVID ST
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City | GULFPORT
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State | MS
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Zip | 39503-3481
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Country | US
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Telephone | 228-832-9191
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Fax | 228-832-9150
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BRENDA G CRUSO
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Credential |
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Telephone | 228-832-9191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 2190
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License Number State | MS
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