Provider Demographics
NPI:1922559665
Name:LIFE RENEWAL NEWTWORK
Entity Type:Organization
Organization Name:LIFE RENEWAL NEWTWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MA, LPC
Authorized Official - Phone:248-474-2763
Mailing Address - Street 1:33634 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-5202
Mailing Address - Country:US
Mailing Address - Phone:248-474-2763
Mailing Address - Fax:248-476-4990
Practice Address - Street 1:33634 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5202
Practice Address - Country:US
Practice Address - Phone:248-474-2763
Practice Address - Fax:248-476-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001490101Y00000X, 101YA0400X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty