Healthcare Provider Details

I. General information

NPI: 1689597833
Provider Name (Legal Business Name): SPECIAL REVELATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 SAN GABRIEL ST
BERNALILLO NM
87004-5648
US

IV. Provider business mailing address

1207 SAN GABRIEL ST
BERNALILLO NM
87004-5648
US

V. Phone/Fax

Practice location:
  • Phone: 505-635-1980
  • Fax:
Mailing address:
  • Phone: 505-635-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CLINTON KESTER
Title or Position: OWNER
Credential:
Phone: 505-635-1980