Provider Demographics
NPI:1780348029
Name:RENASCENT BEHAVIORAL HEALTH CLINIC
Entity type:Organization
Organization Name:RENASCENT BEHAVIORAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:OLUFEMI
Authorized Official - Last Name:OGUNSEYITAN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:817-703-5890
Mailing Address - Street 1:539 W COMMERCE ST STE 3448
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:817-904-4536
Mailing Address - Fax:
Practice Address - Street 1:539 W COMMERCE ST STE 3448
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-1953
Practice Address - Country:US
Practice Address - Phone:817-904-4536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty