Provider Demographics
NPI:1376165639
Name:RENAISSANCE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:RENAISSANCE BEHAVIORAL HEALTH LLC
Other - Org Name:RENAISSANCE BEHAVIORAL HEALTH LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER / CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:TENITA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:440-606-2003
Mailing Address - Street 1:3740 EUCLID AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2229
Mailing Address - Country:US
Mailing Address - Phone:440-606-2003
Mailing Address - Fax:
Practice Address - Street 1:3740 EUCLID AVE STE 101
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2229
Practice Address - Country:US
Practice Address - Phone:440-606-2003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-09
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402869Medicaid