Healthcare Provider Details

I. General information

NPI: 1669764965
Provider Name (Legal Business Name): KATHERINE REVAH GUY L.M.H.C.,L.A.C.,M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FULMER RD
MISHAWAKA IN
46544-6911
US

IV. Provider business mailing address

5725 S BRIDGETON LN
SOUTH BEND IN
46614-6318
US

V. Phone/Fax

Practice location:
  • Phone: 574-274-1162
  • Fax: 888-826-3722
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number86000180A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001988A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: