Healthcare Provider Details

I. General information

NPI: 1528794914
Provider Name (Legal Business Name): REVISION COUNSELING AND WELLNESS, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 FAIRVIEW RD STE 400
CHARLOTTE NC
28210-3119
US

IV. Provider business mailing address

PO BOX 1405
PINEVILLE NC
28134-1405
US

V. Phone/Fax

Practice location:
  • Phone: 704-649-7347
  • Fax:
Mailing address:
  • Phone: 704-649-7347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JARRETT L EVANS
Title or Position: THERAPIST / CEO
Credential: LCMHC
Phone: 704-649-7347