Provider Demographics
NPI:1164279055
Name:REVIVE COUNSELING PROFESSIONALS LLC
Entity type:Organization
Organization Name:REVIVE COUNSELING PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:864-832-2296
Mailing Address - Street 1:202 SANDY SHORES DR
Mailing Address - Street 2:
Mailing Address - City:TOWNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29689-4247
Mailing Address - Country:US
Mailing Address - Phone:864-832-2296
Mailing Address - Fax:
Practice Address - Street 1:202 SANDY SHORES DR
Practice Address - Street 2:
Practice Address - City:TOWNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29689-4247
Practice Address - Country:US
Practice Address - Phone:864-832-2296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty