MEDICARE: RENEWED BEHAVIIORAL HEALTH AND WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	LC5858	MD

General Provider Information

NPI Number	:	1205221934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEWED BEHAVIIORAL HEALTH AND WELLNESS

Provider Business Mailing Address
First Line	:	3914 21ST AVE
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-4320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3914 21ST AVE
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-4320
Country	:	US
Telephone Number	:	757-589-7677
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KIMBERLY A DAVIS
Credential	:	LCPC
Telephone Number	:	757-589-7677

Provider Enumeration Date	:	03/31/2015
Last Update Date	:	03/31/2015

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Directions to “RENEWED BEHAVIIORAL HEALTH AND WELLNESS ” Practice Location

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