Provider Demographics
NPI:1326713215
Name:REVIVAL COUNSELING CENTER
Entity Type:Organization
Organization Name:REVIVAL COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-243-8650
Mailing Address - Street 1:4600 E NETTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6546
Mailing Address - Country:US
Mailing Address - Phone:870-243-8650
Mailing Address - Fax:501-510-5917
Practice Address - Street 1:1632 STRAWFLOOR DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6546
Practice Address - Country:US
Practice Address - Phone:870-243-8650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-12
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)