Provider Demographics
NPI:1629220389
Name:PROFESSIONAL RENEWAL CENTER PA
Entity Type:Organization
Organization Name:PROFESSIONAL RENEWAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:785-842-9772
Mailing Address - Street 1:1201 WAKARUSA DR
Mailing Address - Street 2:SUITE E200
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4722
Mailing Address - Country:US
Mailing Address - Phone:785-842-9772
Mailing Address - Fax:
Practice Address - Street 1:1201 WAKARUSA DR
Practice Address - Street 2:SUITE E200
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4722
Practice Address - Country:US
Practice Address - Phone:785-842-9772
Practice Address - Fax:785-842-5231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty