=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699278283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENEW YOUR MIND - COUNSELING CONSULTING AND SUPERVISION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2018
-----------------------------------------------------
Last Update Date | 05/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15561 RAILROAD ST STE 203A
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54843-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-347-1380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9705N VIOLET LN
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54843-1179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-380-2235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIAL SPECIALIST
-----------------------------------------------------
Name | LESLEY M BOOZELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-232-0856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 302869
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | CC01151
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------