Provider Demographics
NPI:1407439383
Name:RENAISSANCE MENTAL LLC
Entity type:Organization
Organization Name:RENAISSANCE MENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CRUZ DE LA IGLESIA
Authorized Official - Suffix:
Authorized Official - Credentials:CBHCM
Authorized Official - Phone:786-630-8663
Mailing Address - Street 1:18501 PINES BLVD STE 374-375
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18501 PINES BLVD STE 374-375
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1414
Practice Address - Country:US
Practice Address - Phone:786-630-8663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty