Provider Demographics
NPI:1083326706
Name:RESEREVELATIONS, LLC
Entity Type:Organization
Organization Name:RESEREVELATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DE'RESE
Authorized Official - Middle Name:ZYIRE
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:513-328-8516
Mailing Address - Street 1:2606 HILLIARD ROME ROAD PMB 3014
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 N UNION RD
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426
Practice Address - Country:US
Practice Address - Phone:937-350-1684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0307155Medicaid