Provider Demographics
NPI:1598039794
Name:RENEWED LIFE CHRISTIAN COUNSELING CENTER INC
Entity Type:Organization
Organization Name:RENEWED LIFE CHRISTIAN COUNSELING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:R
Authorized Official - Last Name:HASTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:302-464-0515
Mailing Address - Street 1:34 DALTON DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2059
Mailing Address - Country:US
Mailing Address - Phone:302-464-0515
Mailing Address - Fax:302-454-7274
Practice Address - Street 1:3135 SUMMIT BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2001
Practice Address - Country:US
Practice Address - Phone:302-464-0515
Practice Address - Fax:302-454-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE103TP2701X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1972520534Medicaid
DE1000035733Medicaid