Healthcare Provider Details

I. General information

NPI: 1871970566
Provider Name (Legal Business Name): REVENTION RECOVERY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8002 MCEWEN RD
CENTERVILLE OH
45458-2033
US

IV. Provider business mailing address

8002 MCEWEN RD
CENTERVILLE OH
45458-2033
US

V. Phone/Fax

Practice location:
  • Phone: 937-681-9507
  • Fax:
Mailing address:
  • Phone: 937-681-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES M MISJA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 937-260-3156