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General NPI Number Information
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NPI Number | 1003555079
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Entity Type | Organization
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Legal Business Name | REFINED THERAPY GROUP, LLC
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Dates
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Enumeration Date | 05/30/2022
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Last Update Date | 01/21/2023
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Provider Practice Location Address
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Address Line | 1403 43RD AVE STE D
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City | GULFPORT
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State | MS
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Zip | 39501-2545
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Country | US
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Telephone | 601-215-5545
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Fax |
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Provider Business Mailing Address
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Address Line | 2012 W SECOND ST APT 257
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City | LONG BEACH
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State | MS
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Zip | 39560-5513
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Country | US
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Telephone | 228-493-9141
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RIVA CORNELIUS
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Credential | LCSW
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Telephone | 228-493-9141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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