Healthcare Provider Details

I. General information

NPI: 1386405645
Provider Name (Legal Business Name): ANGELA REVERCOMB LPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 NORTHSIDE AVE STE 375
HENRICO VA
23228-5441
US

IV. Provider business mailing address

7901 ANOKA RD
RICHMOND VA
23229-3305
US

V. Phone/Fax

Practice location:
  • Phone: 804-955-8617
  • Fax:
Mailing address:
  • Phone: 804-229-3172
  • 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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA REVERCOMB
Title or Position: OWNER/PROVIDER
Credential: LPC
Phone: 804-955-8617