Provider Demographics
NPI:1609311455
Name:REVOLUTIONARY WELLNESS,PLLC
Entity Type:Organization
Organization Name:REVOLUTIONARY WELLNESS,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:512-569-4017
Mailing Address - Street 1:109 W 7TH ST
Mailing Address - Street 2:SUITE 235
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5763
Mailing Address - Country:US
Mailing Address - Phone:512-788-5634
Mailing Address - Fax:
Practice Address - Street 1:109 W 7TH ST
Practice Address - Street 2:SUITE 235
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5763
Practice Address - Country:US
Practice Address - Phone:512-788-5634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69805101YP2500X
TX391211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty