Provider Demographics
NPI:1598089088
Name:RENAISSANCE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:RENAISSANCE BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:817-939-2376
Mailing Address - Street 1:1101 N LITTLE SCHOOL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1900
Mailing Address - Country:US
Mailing Address - Phone:817-939-2376
Mailing Address - Fax:817-478-4656
Practice Address - Street 1:1101 N LITTLE SCHOOL RD
Practice Address - Street 2:SUITE B
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1900
Practice Address - Country:US
Practice Address - Phone:817-939-2376
Practice Address - Fax:817-478-4656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32135103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162269801Medicaid
TX609952Medicare UPIN