Provider Demographics
NPI:1831647213
Name:REVIVAL COUNSELING SERVICES INCORPORATED
Entity Type:Organization
Organization Name:REVIVAL COUNSELING SERVICES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONICH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-656-8249
Mailing Address - Street 1:4131 HIGH COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4265
Mailing Address - Country:US
Mailing Address - Phone:678-656-8249
Mailing Address - Fax:
Practice Address - Street 1:5357 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-5027
Practice Address - Country:US
Practice Address - Phone:770-942-4742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4829878OtherCIGNA