Provider Demographics
NPI:1003555079
Name:REFINED THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:REFINED THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-493-9141
Mailing Address - Street 1:2012 W SECOND ST APT 257
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-5513
Mailing Address - Country:US
Mailing Address - Phone:228-493-9141
Mailing Address - Fax:
Practice Address - Street 1:1403 43RD AVE STE D
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2545
Practice Address - Country:US
Practice Address - Phone:601-215-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-30
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)