Provider Demographics
NPI:1811417645
Name:REVOLUTIONARY CHANGE COUNSELING LLC
Entity Type:Organization
Organization Name:REVOLUTIONARY CHANGE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC
Authorized Official - Prefix:
Authorized Official - First Name:SHAANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:813-296-7911
Mailing Address - Street 1:1307 APOLLO BEACH BLVD S UNIT 101
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3092
Mailing Address - Country:US
Mailing Address - Phone:813-296-7911
Mailing Address - Fax:
Practice Address - Street 1:1307 APOLLO BEACH BLVD S UNIT 101
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-3092
Practice Address - Country:US
Practice Address - Phone:813-296-7911
Practice Address - Fax:813-200-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty