Basic Information
| Provider Information | |||||||||
| NPI: | 1518234194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENEWED COUNSELING SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13051 GROVE PT | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782535755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102898405 | ||||||||
| FaxNumber: | 2106796705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 NE LOOP 410 | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782175213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102898405 | ||||||||
| FaxNumber: | 2106796705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2011 | ||||||||
| LastUpdateDate: | 11/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | DEMPSEY | ||||||||
| AuthorizedOfficialFirstName: | TARI | ||||||||
| AuthorizedOfficialMiddleName: | SUZETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2102898405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 63113 | TX | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 202676701 | 05 | TX | MEDICAID |