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General NPI Number Information
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NPI Number | 1114682960
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Entity Type | Organization
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Legal Business Name | REVITALIZING INNER SELF ESSENCE LLC
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Dates
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Enumeration Date | 11/07/2021
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Last Update Date | 11/07/2021
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Provider Practice Location Address
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Address Line | 17 WARREN RD STE 3A
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City | PIKESVILLE
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State | MD
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Zip | 21208-5001
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Country | US
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Telephone | 410-929-6632
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1448
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City | OWINGS MILLS
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State | MD
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Zip | 21117-1403
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTINA SIMMONS
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Credential |
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Telephone | 410-929-6632
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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