Provider Demographics
NPI:1902285877
Name:RENEGADE COUNSELING, PLLC
Entity Type:Organization
Organization Name:RENEGADE COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBBY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:PLYMALE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-427-3944
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-0262
Mailing Address - Country:US
Mailing Address - Phone:918-427-3944
Mailing Address - Fax:
Practice Address - Street 1:809-B SOUTH BIRCH STREET
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948
Practice Address - Country:US
Practice Address - Phone:918-427-3944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5354251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health