Provider Demographics
NPI:1447679519
Name:MIND RENEWAL SERVICES, LLC
Entity type:Organization
Organization Name:MIND RENEWAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON-FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:443-867-6663
Mailing Address - Street 1:439 CONGAREE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2867
Mailing Address - Country:US
Mailing Address - Phone:864-509-9087
Mailing Address - Fax:864-509-9072
Practice Address - Street 1:439 CONGAREE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2867
Practice Address - Country:US
Practice Address - Phone:864-509-9087
Practice Address - Fax:864-509-9072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1164Medicaid