Provider Demographics
NPI:1811540909
Name:REVOLUTION PSYCHOTHERAPY, A FAMILY AND MARRIAGE THERAPY CORPORATION
Entity Type:Organization
Organization Name:REVOLUTION PSYCHOTHERAPY, A FAMILY AND MARRIAGE THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CALIFORNIA LMFT
Authorized Official - Phone:805-888-9254
Mailing Address - Street 1:901 MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-2927
Mailing Address - Country:US
Mailing Address - Phone:805-888-9254
Mailing Address - Fax:805-669-3525
Practice Address - Street 1:3319 TELEGRAPH RD STE 108
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3319
Practice Address - Country:US
Practice Address - Phone:805-888-9254
Practice Address - Fax:805-669-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346513363OtherNPPES