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General NPI Number Information
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NPI Number | 1750759262
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Entity Type | Organization
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Legal Business Name | RENEWED SPIRITS, LLC
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 6675 MEDITERRANEAN DR
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City | MCKINNEY
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State | TX
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Zip | 75070-5573
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Country | US
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Telephone | 214-945-3744
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Fax |
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Provider Business Mailing Address
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Address Line | 4011 BLACK OAK DR
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City | CARROLLTON
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State | TX
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Zip | 75007-1027
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Country | US
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Telephone | 214-945-3744
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | MICHELE DENISE FESENBEK
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Credential | LPC
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Telephone | 214-945-3744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 70386
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License Number State | TX
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