Provider Demographics
NPI:1821766320
Name:REVIVAL COUNSELING LLC
Entity Type:Organization
Organization Name:REVIVAL COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAYLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DURNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:814-282-5489
Mailing Address - Street 1:7264 S WOODROW DR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9102
Mailing Address - Country:US
Mailing Address - Phone:814-282-5489
Mailing Address - Fax:765-227-2162
Practice Address - Street 1:7264 S WOODROW DR
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9102
Practice Address - Country:US
Practice Address - Phone:814-282-5489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-31
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty