Healthcare Provider Details

I. General information

NPI: 1639003775
Provider Name (Legal Business Name): REVISE COUNSELING & CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5324 MACCORKLE AVE SE STE A
CHARLESTON WV
25304-2200
US

IV. Provider business mailing address

PO BOX 4041
CHARLESTON WV
25364-4041
US

V. Phone/Fax

Practice location:
  • Phone: 304-205-1988
  • Fax:
Mailing address:
  • Phone: 304-205-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KELLY MASON
Title or Position: OWNER
Credential: PHD, LPC, ALPS
Phone: 304-205-1988