Provider Demographics
NPI:1639873565
Name:RENEWED THERAPY & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:RENEWED THERAPY & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WAJAHATUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-817-5928
Mailing Address - Street 1:343 N WOOD DALE RD STE 201A
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1578
Mailing Address - Country:US
Mailing Address - Phone:773-817-5928
Mailing Address - Fax:
Practice Address - Street 1:12712 W LAKE HOUSTON PKWY STE B4136
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77044-6467
Practice Address - Country:US
Practice Address - Phone:850-625-1788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty