Provider Demographics
NPI:1538637277
Name:REVEL LIVING LLC
Entity type:Organization
Organization Name:REVEL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-952-8263
Mailing Address - Street 1:2619 CENTRAL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-6415
Mailing Address - Country:US
Mailing Address - Phone:619-952-8263
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE STE 305
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5909
Practice Address - Country:US
Practice Address - Phone:312-899-6184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-12
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health