Provider Demographics
NPI:1831922293
Name:RENEGADE WELLNESS
Entity type:Organization
Organization Name:RENEGADE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SURGI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-987-5655
Mailing Address - Street 1:725 WASHINGTON ST APT 108
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 WASHINGTON ST APT 108
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2243
Practice Address - Country:US
Practice Address - Phone:224-300-0987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health