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General NPI Number Information
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NPI Number | 1043618333
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Entity Type | Organization
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Legal Business Name | LIFE REVISE COUNSELING
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Dates
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Enumeration Date | 12/18/2014
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Last Update Date | 12/18/2014
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Provider Practice Location Address
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Address Line | 2321 S BELT LINE RD STE 117
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City | GRAND PRAIRIE
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State | TX
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Zip | 75051-4181
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Country | US
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Telephone | 817-821-3690
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Fax |
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Provider Business Mailing Address
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Address Line | 2824 PARK PLACE DR
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City | GRAND PRAIRIE
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State | TX
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Zip | 75052-8521
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Country | US
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Telephone | 817-821-3690
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHELLE PALACIOS
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Credential | LPC-S
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Telephone | 817-821-3690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 64640
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License Number State | TX
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