Provider Demographics
NPI:1093201444
Name:REVOLUTION COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:REVOLUTION COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STEARNS-LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISW
Authorized Official - Phone:309-781-4053
Mailing Address - Street 1:601 BRADY ST STE 204
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5251
Mailing Address - Country:US
Mailing Address - Phone:309-781-4053
Mailing Address - Fax:309-792-2440
Practice Address - Street 1:601 BRADY ST STE 204
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5251
Practice Address - Country:US
Practice Address - Phone:309-781-4053
Practice Address - Fax:309-792-2440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0788211041C0700X
IL1490191311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1831565290Medicaid