Provider Demographics
NPI:1033137724
Name:RENEW BEHAVORIAL HEALTH INC
Entity Type:Organization
Organization Name:RENEW BEHAVORIAL HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAJA
Authorized Official - Middle Name:I
Authorized Official - Last Name:IBRAHEEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-637-3143
Mailing Address - Street 1:PO BOX 20140
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-3140
Mailing Address - Country:US
Mailing Address - Phone:562-637-3143
Mailing Address - Fax:562-637-3244
Practice Address - Street 1:4000 LONG BEACH BLVD
Practice Address - Street 2:STE 228
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2617
Practice Address - Country:US
Practice Address - Phone:562-637-3143
Practice Address - Fax:562-637-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A661240Medicaid
CA00A661240Medicaid
CAA66124Medicare ID - Type Unspecified