Provider Demographics
NPI:1376151969
Name:REVIVED AND RENEWED MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:REVIVED AND RENEWED MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LCSW
Authorized Official - Phone:337-450-0406
Mailing Address - Street 1:4400 AMBASSADOR CAFFERY PKWY STE A167
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6760
Mailing Address - Country:US
Mailing Address - Phone:337-450-0406
Mailing Address - Fax:
Practice Address - Street 1:4400 AMBASSADOR CAFFERY PKWY STE A167
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6760
Practice Address - Country:US
Practice Address - Phone:337-450-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health