Provider Demographics
NPI:1558926113
Name:RENEW THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:RENEW THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-820-6476
Mailing Address - Street 1:2924 KNIGHT ST STE 424
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2413
Mailing Address - Country:US
Mailing Address - Phone:318-820-6476
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 424
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2413
Practice Address - Country:US
Practice Address - Phone:318-820-6476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health