1033886908 NPI number — RENEWED JOURNEY PSYCHOLOGICAL SERVICES LLC

Table of content: (NPI 1033886908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033886908 NPI number — RENEWED JOURNEY PSYCHOLOGICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEWED JOURNEY PSYCHOLOGICAL SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033886908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19066
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85731-9066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-904-5277
Provider Business Mailing Address Fax Number:
855-718-2713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5442 E 5TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-904-5277
Provider Business Practice Location Address Fax Number:
520-904-5277
Provider Enumeration Date:
08/26/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
520-904-5277

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 195157 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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