Healthcare Provider Details

I. General information

NPI: 1730701905
Provider Name (Legal Business Name): RE'VIN SLACK MS, LMFT, APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 OAK MANOR DR
COLUMBIA SC
29229-9313
US

IV. Provider business mailing address

PO BOX 292493
COLUMBIA SC
29229-0042
US

V. Phone/Fax

Practice location:
  • Phone: 909-522-9690
  • Fax:
Mailing address:
  • Phone: 909-522-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT8060
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT135690
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: