Provider Demographics
NPI:1518421577
Name:RENITA SHORES-GASTON
Entity Type:Organization
Organization Name:RENITA SHORES-GASTON
Other - Org Name:RESILIENCE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORES-GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-543-2789
Mailing Address - Street 1:5844 ELAINE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2494
Mailing Address - Country:US
Mailing Address - Phone:815-373-3027
Mailing Address - Fax:
Practice Address - Street 1:5844 ELAINE DR STE 101
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2494
Practice Address - Country:US
Practice Address - Phone:815-373-3027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL358782826001Medicaid