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General NPI Number Information
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NPI Number | 1184132094
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Entity Type | Organization
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Legal Business Name | REVITALIZE COUNSELING SERVICES LLC
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Dates
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Enumeration Date | 01/12/2018
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Last Update Date | 01/12/2018
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Provider Practice Location Address
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Address Line | 2401 WOODLAND RD
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City | MANCHESTER
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State | NJ
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Zip | 08759-6135
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Country | US
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Telephone | 848-459-5943
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Fax |
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Provider Business Mailing Address
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Address Line | 2401 WOODLAND RD
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City | MANCHESTER
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State | NJ
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Zip | 08759-6135
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Country | US
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Telephone | 848-459-5943
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. DANA M GIBILISCO
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Credential | MS, LPC, NCC
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Telephone | 848-459-5943
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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 | 37PC00555800
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License Number State | NJ
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