Provider Demographics
NPI:1285388140
Name:RENEWED MIND ENRICHMENT THERAPY & COMMUNITY SERVICES NETWORK
Entity type:Organization
Organization Name:RENEWED MIND ENRICHMENT THERAPY & COMMUNITY SERVICES NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & LICENSED PROFESSIONAL THERA
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:580-231-1659
Mailing Address - Street 1:5506 W CHESTNUT AVE, APT 222
Mailing Address - Street 2:5506 W CHESTNUT AVE, APT 222
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703
Mailing Address - Country:US
Mailing Address - Phone:580-231-1659
Mailing Address - Fax:855-629-7098
Practice Address - Street 1:5506 W CHESTNUT AVE, APT 222
Practice Address - Street 2:5506 W CHESTNUT AVE, APT 222
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703
Practice Address - Country:US
Practice Address - Phone:580-231-1659
Practice Address - Fax:855-629-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)