Provider Demographics
NPI:1255009783
Name:REVIVE COUNSELING LLC
Entity Type:Organization
Organization Name:REVIVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA-VESKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-609-1758
Mailing Address - Street 1:4188 COVE LN APT C
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8052 MONTICELLO AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3438
Practice Address - Country:US
Practice Address - Phone:773-609-1758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1669986915OtherSELF-PAY, COMMERCIAL INSURANCE