Provider Demographics
NPI:1225472632
Name:REVEIVE YOUTH AND FAMILY SERVICES
Entity Type:Organization
Organization Name:REVEIVE YOUTH AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:CAPSW
Authorized Official - Phone:414-763-6603
Mailing Address - Street 1:2518 N17TH ST.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206
Mailing Address - Country:US
Mailing Address - Phone:414-915-2637
Mailing Address - Fax:414-810-1567
Practice Address - Street 1:2518 N 17TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2020
Practice Address - Country:US
Practice Address - Phone:414-915-2637
Practice Address - Fax:414-810-1567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8035461322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children