Provider Demographics
NPI:1386902765
Name:RENAISSANCE RECOVERY CENTER LLC
Entity type:Organization
Organization Name:RENAISSANCE RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:RALLIS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-632-1345
Mailing Address - Street 1:459 N GILBERT RD
Mailing Address - Street 2:SUITE B140
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4591
Mailing Address - Country:US
Mailing Address - Phone:480-632-1345
Mailing Address - Fax:480-632-1354
Practice Address - Street 1:459 N GILBERT RD
Practice Address - Street 2:SUITE B140
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4591
Practice Address - Country:US
Practice Address - Phone:480-632-1345
Practice Address - Fax:480-632-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty