Provider Demographics
NPI:1043618333
Name:LIFE REVISE COUNSELING
Entity Type:Organization
Organization Name:LIFE REVISE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PALACIOS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:817-821-3690
Mailing Address - Street 1:2824 PARK PLACE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8521
Mailing Address - Country:US
Mailing Address - Phone:817-821-3690
Mailing Address - Fax:
Practice Address - Street 1:2321 S BELT LINE RD STE 117
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4181
Practice Address - Country:US
Practice Address - Phone:817-821-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64640251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health