MEDICARE: RENAISSANCE MENTAL HEALTH CORPORATION

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1881295848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE MENTAL HEALTH CORPORATION

Provider Business Mailing Address
First Line	:	3663 E SUNSET RD STE 201C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3246
Country	:	US
Telephone Number	:	702-930-5958
Fax Number	:	702-920-8475

Provider Business Practice Location Address
First Line	:	3663 E SUNSET RD STE 201C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3246
Country	:	US
Telephone Number	:	702-930-5958
Fax Number	:	702-920-8475

Authorized Official
Title or Position	:	OWNER/MANAGING MEMBER
Name	:	DR. GWENDOLYN T GREENE
Credential	:	DBH
Telephone Number	:	702-930-5958

Provider Enumeration Date	:	11/05/2020
Last Update Date	:	11/05/2020

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