Provider Demographics
NPI:1407180284
Name:RENAISSANCE THERAPY CLINIC PLLC
Entity Type:Organization
Organization Name:RENAISSANCE THERAPY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:VANDALOV
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LPC, NCC
Authorized Official - Phone:248-990-0140
Mailing Address - Street 1:1O WEST SQUARE LAKE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0466
Mailing Address - Country:US
Mailing Address - Phone:248-990-0140
Mailing Address - Fax:888-510-9669
Practice Address - Street 1:1O WEST SQUARE LAKE RD
Practice Address - Street 2:SUITE 221
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0466
Practice Address - Country:US
Practice Address - Phone:248-990-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005273101YP2500X
MI6301000821103TC0700X
MI68010699061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty