Healthcare Provider Details

I. General information

NPI: 1114682960
Provider Name (Legal Business Name): REVITALIZING INNER SELF ESSENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 11/07/2021
Certification Date: 11/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 WARREN RD STE 3A
PIKESVILLE MD
21208-5001
US

IV. Provider business mailing address

PO BOX 1448
OWINGS MILLS MD
21117-1403
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-6632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA SIMMONS
Title or Position: OWNER
Credential:
Phone: 410-929-6632