Provider Demographics
NPI:1801443858
Name:RENEW BEHAVIOR SERVICES LLC
Entity type:Organization
Organization Name:RENEW BEHAVIOR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:812-569-4884
Mailing Address - Street 1:524 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-1902
Mailing Address - Country:US
Mailing Address - Phone:812-569-4884
Mailing Address - Fax:
Practice Address - Street 1:524 N ELM ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1902
Practice Address - Country:US
Practice Address - Phone:812-569-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty