Organization
RENAISSANCE THERAPY CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. VLADIMIR ROBERT VANDALOV PSYD, LPC, NCC (OWNER)
(248) 990-0140
Entity
Organization
Contact information
Practice address
1O WEST SQUARE LAKE RD, SUITE 221, BLOOMFIELD HILLS, MI 48302-0466
(248) 990-0140
Mailing address
1O WEST SQUARE LAKE RD, SUITE 101, BLOOMFIELD HILLS, MI 48302-0466
(248) 990-0140
(888) 510-9669
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
6401005273
MI
103TC0700X
Clinical Psychologist
6301000821
MI
1041C0700X
Clinical Social Worker
6801069906
MI
Other
Enumeration date
09/25/2009
Last updated
07/27/2010
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