Renaissance Therapy Clinic PLLC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

6401005273 Issued in MI

Legal business name

RENAISSANCE THERAPY CLINIC PLLC

Practice address

1O West Square Lake Rd
Suite 221
Bloomfield Hills, MI 48302-0466

Phone

(248) 990-0140

NPI assigned

Sep 25, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Vladimir Robert Vandalov, PSYD, LPC, NCC

Title

Owner

Phone

(248) 990-0140

Specialties & licenses 3

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1253836800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1280188800000",
    "number": "1407180284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1O WEST SQUARE LAKE RD",
            "address_2": "SUITE 101",
            "city": "BLOOMFIELD HILLS",
            "state": "MI",
            "postal_code": "483020466",
            "telephone_number": "248-990-0140",
            "fax_number": "888-510-9669"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1O WEST SQUARE LAKE RD",
            "address_2": "SUITE 221",
            "city": "BLOOMFIELD HILLS",
            "state": "MI",
            "postal_code": "483020466",
            "telephone_number": "248-990-0140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RENAISSANCE THERAPY CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-09-25",
        "last_updated": "2010-07-27",
        "status": "A",
        "authorized_official_last_name": "VANDALOV",
        "authorized_official_first_name": "VLADIMIR",
        "authorized_official_middle_name": "ROBERT",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "248-990-0140",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSYD, LPC, NCC"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "MI",
            "license": "6401005273",
            "primary": true
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "MI",
            "license": "6301000821",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "MI",
            "license": "6801069906",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Professional Counselor in Bloomfield Hills, MI
• Providers in Bloomfield Hills, MI by specialty
• Professional Counselor in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.