MEDICARE: CHILDRENS GRIEF CENTER OF EL PASO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1154127470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDRENS GRIEF CENTER OF EL PASO

Provider Business Mailing Address
First Line	:	2616 MONTANA AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79903-3712
Country	:	US
Telephone Number	:	915-532-6004
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 MONTANA AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79903-3712
Country	:	US
Telephone Number	:	915-532-6004
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	KATHRYN LEIGH REVTYAK
Credential	:	LCSW-S
Telephone Number	:	915-525-9482

Provider Enumeration Date	:	02/19/2025
Last Update Date	:	05/15/2026

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