Provider Demographics
NPI:1083323570
Name:REVIVED MIND COUNSELING SERVICES
Entity Type:Organization
Organization Name:REVIVED MIND COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-483-2461
Mailing Address - Street 1:2705 TAPESTRY DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4611
Mailing Address - Country:US
Mailing Address - Phone:517-930-9950
Mailing Address - Fax:
Practice Address - Street 1:2705 TAPESTRY DR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4611
Practice Address - Country:US
Practice Address - Phone:517-930-9950
Practice Address - Fax:517-323-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty