Provider Demographics
NPI:1134607898
Name:RENEW PSYCHIATRY SERVICES
Entity type:Organization
Organization Name:RENEW PSYCHIATRY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHIE
Authorized Official - Middle Name:ARMELL
Authorized Official - Last Name:BOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:678-900-0308
Mailing Address - Street 1:5715 GLEN HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4064
Mailing Address - Country:US
Mailing Address - Phone:678-900-0308
Mailing Address - Fax:540-204-4097
Practice Address - Street 1:177 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:678-900-0308
Practice Address - Fax:540-204-4097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty