Provider Demographics
NPI:1720802341
Name:RENEW MENTAL HEALTH AND WELLNESS, LLC
Entity type:Organization
Organization Name:RENEW MENTAL HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AUTUM
Authorized Official - Middle Name:
Authorized Official - Last Name:BRECKENRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-243-3644
Mailing Address - Street 1:1150 E MATTHEWS AVE STE 101A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4356
Mailing Address - Country:US
Mailing Address - Phone:870-243-0424
Mailing Address - Fax:
Practice Address - Street 1:1150 E MATTHEWS AVE STE 101A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4356
Practice Address - Country:US
Practice Address - Phone:870-243-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENEW MENTAL HEALTH AND WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1679724504Medicaid