Provider Demographics
NPI:1275124711
Name:MIND REVOLUTION COUNSELING AND CONSULTING
Entity Type:Organization
Organization Name:MIND REVOLUTION COUNSELING AND CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:URIBE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-307-3007
Mailing Address - Street 1:16772 W BELL RD STE 110-449
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9702
Mailing Address - Country:US
Mailing Address - Phone:623-252-0163
Mailing Address - Fax:
Practice Address - Street 1:501 E PLAZA CIR STE B
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4917
Practice Address - Country:US
Practice Address - Phone:623-252-0163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)