Basic Information
| Provider Information | |||||||||
| NPI: | 1487937066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | A RENEWED MIND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1704 CASS RD | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435372331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149620264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 W SOUTH BOUNDARY ST BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435515230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198738280 | ||||||||
| FaxNumber: | 4198738320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2011 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | EARLE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | JEFFREY | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4198738280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MAE, MRC; CDCA; LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | C.0500399 | OH | Y | Agencies | Community/Behavioral Health |
No ID Information.