Provider Demographics
NPI:1124844600
Name:CONSCIOUS RENEWING THERAPY
Entity type:Organization
Organization Name:CONSCIOUS RENEWING THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEKEYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LCSW
Authorized Official - Phone:470-263-6320
Mailing Address - Street 1:3863 HIGHWAY 138 SE # 1379
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4143
Mailing Address - Country:US
Mailing Address - Phone:470-263-7264
Mailing Address - Fax:
Practice Address - Street 1:3100 STONE BRIDGE TRL SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6713
Practice Address - Country:US
Practice Address - Phone:470-263-6320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty