Provider Demographics
NPI:1114429412
Name:REVERE COUNSELING AND CARE MANAGEMENT LLC
Entity Type:Organization
Organization Name:REVERE COUNSELING AND CARE MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-736-3793
Mailing Address - Street 1:235 E PONCE DE LEON AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3452
Mailing Address - Country:US
Mailing Address - Phone:404-281-5422
Mailing Address - Fax:404-377-0750
Practice Address - Street 1:235 E PONCE DE LEON AVE STE 330
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3452
Practice Address - Country:US
Practice Address - Phone:404-281-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW002619104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty