Provider Demographics
NPI:1972520534
Name:RENEWED LIFE CHRISTIAN COUNSELING CENTER
Entity Type:Organization
Organization Name:RENEWED LIFE CHRISTIAN COUNSELING CENTER
Other - Org Name:RLCCC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/DIRECTOR/COUNSELOR
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:302-275-8577
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:
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:302-275-8577
Practice Address - Fax:302-454-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00007651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000035733Medicaid
DE1000039721Medicaid