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General NPI Number Information
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NPI Number | 1114429412
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Entity Type | Organization
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Legal Business Name | REVERE COUNSELING AND CARE MANAGEMENT LLC
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Dates
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Enumeration Date | 03/02/2018
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Last Update Date | 07/19/2022
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Provider Practice Location Address
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Address Line | 235 E PONCE DE LEON AVE STE 330
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City | DECATUR
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State | GA
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Zip | 30030-3452
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Country | US
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Telephone | 404-281-5422
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Fax |
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Provider Business Mailing Address
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Address Line | 235 E PONCE DE LEON AVE STE 330
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City | DECATUR
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State | GA
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Zip | 30030-3452
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Country | US
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Telephone | 404-281-5422
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Fax | 404-377-0750
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE LYNN ROACH
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Credential | LCSW
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Telephone | 404-736-3793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | CSW002619
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License Number State | GA
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