Provider Demographics
NPI:1457723587
Name:A RENEWAL CENTER LLC
Entity Type:Organization
Organization Name:A RENEWAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR,PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:VIRGINIA
Authorized Official - Last Name:WHITMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC,CDP,NCGCII/BACC
Authorized Official - Phone:425-227-0447
Mailing Address - Street 1:533 REDMOND PL NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3988
Mailing Address - Country:US
Mailing Address - Phone:425-227-0447
Mailing Address - Fax:
Practice Address - Street 1:401 OLYMPIA AVE NE STE 318
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4117
Practice Address - Country:US
Practice Address - Phone:425-227-0447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60528456302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110000273418Medicaid