Provider Demographics
NPI:1225404551
Name:FAMILY RENEWED, LLC
Entity Type:Organization
Organization Name:FAMILY RENEWED, LLC
Other - Org Name:DAWN M. PORTER, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-461-0369
Mailing Address - Street 1:1004 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-2834
Mailing Address - Country:US
Mailing Address - Phone:913-461-0369
Mailing Address - Fax:913-461-0832
Practice Address - Street 1:1004 PEBBLE BEACH DR
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232-2834
Practice Address - Country:US
Practice Address - Phone:913-461-0369
Practice Address - Fax:913-461-0832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1136802084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty