Provider Demographics
NPI:1295314136
Name:REVAMP & PREVAIL THERAPY, PLLC
Entity type:Organization
Organization Name:REVAMP & PREVAIL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:704-737-8242
Mailing Address - Street 1:1213 W MOREHEAD ST STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5581
Mailing Address - Country:US
Mailing Address - Phone:704-737-8242
Mailing Address - Fax:
Practice Address - Street 1:1213 W MOREHEAD ST STE 500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5581
Practice Address - Country:US
Practice Address - Phone:704-737-8242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty