Provider Demographics
NPI:1710717392
Name:RENEWED OAKS THERAPY LLC
Entity type:Organization
Organization Name:RENEWED OAKS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSENAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:479-879-5916
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-0034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 SOUTHWINDS RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-8678
Practice Address - Country:US
Practice Address - Phone:479-267-6934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)