Provider Demographics
NPI:1275388985
Name:COURAGE ON PURPOSE
Entity Type:Organization
Organization Name:COURAGE ON PURPOSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:REVERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-415-5993
Mailing Address - Street 1:2473 S HIGLEY RD # 104-124
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1103
Mailing Address - Country:US
Mailing Address - Phone:904-415-5993
Mailing Address - Fax:
Practice Address - Street 1:2473 S HIGLEY RD # 104-124
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1103
Practice Address - Country:US
Practice Address - Phone:602-491-5928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty