Healthcare Provider Details

I. General information

NPI: 1538637277
Provider Name (Legal Business Name): REVEL LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 RIDGE AVE STE 305
EVANSTON IL
60201-5909
US

IV. Provider business mailing address

2619 CENTRAL ST APT 3
EVANSTON IL
60201-6415
US

V. Phone/Fax

Practice location:
  • Phone: 312-899-6184
  • Fax:
Mailing address:
  • Phone: 619-952-8263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK VAUGHAN
Title or Position: OWNER/THERAPIST
Credential: LMFT
Phone: 619-952-8263