Provider Demographics
NPI:1811527500
Name:REVITALIFE THERAPY & COUNSELING LLC
Entity type:Organization
Organization Name:REVITALIFE THERAPY & COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-231-2668
Mailing Address - Street 1:212 BILLETTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27921-7505
Mailing Address - Country:US
Mailing Address - Phone:252-231-2668
Mailing Address - Fax:252-377-4231
Practice Address - Street 1:1101 EXECUTIVE BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3634
Practice Address - Country:US
Practice Address - Phone:252-231-2668
Practice Address - Fax:252-377-4231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty