Provider Demographics
NPI:1174122170
Name:RENEWED VISION COUNSELING AND DEVELOPMENTAL DISABILITY CENTER PC
Entity type:Organization
Organization Name:RENEWED VISION COUNSELING AND DEVELOPMENTAL DISABILITY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:PLMHP
Authorized Official - Phone:531-876-7455
Mailing Address - Street 1:4642 S. 132ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1764
Mailing Address - Country:US
Mailing Address - Phone:531-876-7455
Mailing Address - Fax:
Practice Address - Street 1:4610 S. 133RD ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1133
Practice Address - Country:US
Practice Address - Phone:402-275-6413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026845900Medicaid