Provider Demographics
NPI:1043454218
Name:RENEWED VISION FAMILY, COMMUNITY AND MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:RENEWED VISION FAMILY, COMMUNITY AND MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:P-LCSW
Authorized Official - Phone:347-645-8375
Mailing Address - Street 1:5438 CRISFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0152
Mailing Address - Country:US
Mailing Address - Phone:704-596-0940
Mailing Address - Fax:
Practice Address - Street 1:9700 RESEARCH DR STE 138
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8585
Practice Address - Country:US
Practice Address - Phone:704-726-0018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management