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General NPI Number Information
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NPI Number | 1760617138
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Entity Type | Organization
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Legal Business Name | RENEW COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 05/28/2009
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Last Update Date | 05/28/2009
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Provider Practice Location Address
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Address Line | 3356 KIMBALL AVE SUITE 3
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City | WATERLOO
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State | IA
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Zip | 50702-5700
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Country | US
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Telephone | 319-464-2940
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Fax |
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Provider Business Mailing Address
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Address Line | 3356 KIMBALL AVE SUITE 3
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City | WATERLOO
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State | IA
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Zip | 50702-5700
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Country | US
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Telephone | 319-464-2940
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRUCE ALAN GREGORY
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Credential | MA
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Telephone | 319-464-2940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 00975
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License Number State | IA
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