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General NPI Number Information
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NPI Number | 1811452188
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Entity Type | Organization
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Legal Business Name | RENEWED LIFE COUNSELING, LLC
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Dates
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Enumeration Date | 01/31/2019
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Last Update Date | 01/31/2019
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Provider Practice Location Address
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Address Line | 10026 UNIVERSITY AVE NW STE 103
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City | COON RAPIDS
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State | MN
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Zip | 55448-2213
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Country | US
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Telephone | 612-636-9677
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Fax |
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Provider Business Mailing Address
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Address Line | 10026 UNIVERSITY AVE NW STE 103
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City | COON RAPIDS
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State | MN
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Zip | 55448-2213
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Country | US
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Telephone | 612-636-9677
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | NIKISHA LYNNETTE SIMMONS-MACLIN
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Credential | LADC
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Telephone | 612-636-9677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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