Healthcare Provider Details

I. General information

NPI: 1982146718
Provider Name (Legal Business Name): REVITA DECHALUS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3436 N KENNICOTT AVE
ARLINGTON HEIGHTS IL
60004-7814
US

IV. Provider business mailing address

3436 N KENNICOTT AVE
ARLINGTON HEIGHTS IL
60004-7814
US

V. Phone/Fax

Practice location:
  • Phone: 947-952-7460
  • Fax: 847-222-1754
Mailing address:
  • Phone: 947-952-7460
  • Fax: 847-222-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178006723
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: