Provider Demographics
NPI:1093171084
Name:RENEW THERAPY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:RENEW THERAPY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-271-8579
Mailing Address - Street 1:3029 CANOPY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-8794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 SWIFTSIDE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7200
Practice Address - Country:US
Practice Address - Phone:919-271-8579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0053371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty