MEDICARE: RENASCENCE CENTER, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP1600X	Pastoral Counselor
2	103TC0700X	Clinical Psychologist
3	1041C0700X	Clinical Social Worker
4	106H00000X	Marriage & Family Therapist
5	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1508156266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENASCENCE CENTER, LLC

Provider Business Mailing Address
First Line	:	46 S GLEBE RD STE 103
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22204-1671
Country	:	US
Telephone Number	:	703-521-6004
Fax Number	:	703-521-6342

Provider Business Practice Location Address
First Line	:	46 S GLEBE RD STE 103
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22204-1671
Country	:	US
Telephone Number	:	703-521-6004
Fax Number	:	703-521-6342

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	NANCY GRAY
Credential	:
Telephone Number	:	703-521-6004

Provider Enumeration Date	:	04/15/2011
Last Update Date	:	04/15/2011

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