=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124504642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITALIZING RELATIONSHIPS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 SWIFT BLVD STE 7
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99352-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-338-0827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1761 GEORGE WASHINGTON WAY # 349
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99354-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-338-0827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LIC. MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | RONDA EVANS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 707-338-0827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LF60618799
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LF60618799
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------