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General NPI Number Information
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NPI Number | 1053119446
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Entity Type | Organization
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Legal Business Name | REVIVING THERAPY & CONSULTING LLC
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 2136 FORD PKWY
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City | SAINT PAUL
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State | MN
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Zip | 55116-2850
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Country | US
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Telephone | 605-350-5232
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Fax |
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Provider Business Mailing Address
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Address Line | 12460 CORAL SEA ST NE
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City | BLAINE
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State | MN
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Zip | 55449-6232
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Country | US
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Telephone | 605-350-5232
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL CLINICAL COUN
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Name | EMMANUEL NWALA
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Credential | PHD, LPCC
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Telephone | 605-350-5232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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