Provider Demographics
NPI:1144780222
Name:RENEW COUNSELING
Entity Type:Organization
Organization Name:RENEW COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-410-7719
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38281-0073
Mailing Address - Country:US
Mailing Address - Phone:731-592-1987
Mailing Address - Fax:731-681-2823
Practice Address - Street 1:108 S 1ST ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-3802
Practice Address - Country:US
Practice Address - Phone:731-592-1987
Practice Address - Fax:731-681-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-23
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012336Medicaid
TNQ017284Medicaid
TNQ051441Medicaid