=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780348029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENASCENT BEHAVIORAL HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2021
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 539 W COMMERCE ST STE 3448
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-904-4536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 W COMMERCE ST STE 3448
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75208-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-904-4536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ISAAC OLUFEMI OGUNSEYITAN
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 817-703-5890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------