Healthcare Provider Details

I. General information

NPI: 1184310732
Provider Name (Legal Business Name): REVEALED PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 04/17/2023
Certification Date: 04/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 W LONG SHADOW TRL
PHOENIX AZ
85085-6084
US

IV. Provider business mailing address

2309 W LONG SHADOW TRL
PHOENIX AZ
85085-6084
US

V. Phone/Fax

Practice location:
  • Phone: 907-590-5015
  • Fax:
Mailing address:
  • Phone: 907-590-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. MELODIE SIMMONS
Title or Position: CEO/FOUNDER
Credential: MS, LPC, CEDS-S
Phone: 907-590-5015