Provider Demographics
NPI:1952062770
Name:REVAMPED RELATIONSHIPS
Entity Type:Organization
Organization Name:REVAMPED RELATIONSHIPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELBY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-517-3504
Mailing Address - Street 1:631 N CARROLL PKWY APT 209
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1161
Mailing Address - Country:US
Mailing Address - Phone:773-517-3504
Mailing Address - Fax:
Practice Address - Street 1:631 N CARROLL PKWY APT 209
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-1161
Practice Address - Country:US
Practice Address - Phone:708-637-6760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)