Healthcare Provider Details

I. General information

NPI: 1821766320
Provider Name (Legal Business Name): REVIVAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7264 S WOODROW DR
PENDLETON IN
46064-9102
US

IV. Provider business mailing address

7264 S WOODROW DR
PENDLETON IN
46064-9102
US

V. Phone/Fax

Practice location:
  • Phone: 814-282-5489
  • Fax:
Mailing address:
  • Phone: 814-282-5489
  • Fax: 765-227-2162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAYLEE DURNELL
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 814-282-5489