Provider Demographics
NPI:1033740196
Name:MIND RENEW,LLC
Entity Type:Organization
Organization Name:MIND RENEW,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHOCKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERSNO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-953-2501
Mailing Address - Street 1:17569 W BANFF LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-7891
Mailing Address - Country:US
Mailing Address - Phone:404-953-2501
Mailing Address - Fax:
Practice Address - Street 1:12211 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9521
Practice Address - Country:US
Practice Address - Phone:404-953-2501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty