Provider Demographics
NPI:1912561713
Name:REVIVICATION COUNSELING SERVICES
Entity Type:Organization
Organization Name:REVIVICATION COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEVITICUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-447-0102
Mailing Address - Street 1:PO BOX 1211
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439
Mailing Address - Country:US
Mailing Address - Phone:757-477-0102
Mailing Address - Fax:757-477-0142
Practice Address - Street 1:321 N MAIN ST SUITE C
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4422
Practice Address - Country:US
Practice Address - Phone:727-477-0102
Practice Address - Fax:757-477-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-26
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty