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General NPI Number Information
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NPI Number | 1386405645
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Entity Type | Organization
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Legal Business Name | ANGELA REVERCOMB LPC LLC
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Dates
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Enumeration Date | 01/23/2024
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Last Update Date | 01/23/2024
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Provider Practice Location Address
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Address Line | 3111 NORTHSIDE AVE STE 375
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City | HENRICO
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State | VA
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Zip | 23228-5441
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Country | US
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Telephone | 804-955-8617
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Fax |
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Provider Business Mailing Address
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Address Line | 7901 ANOKA RD
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City | RICHMOND
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State | VA
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Zip | 23229-3305
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Country | US
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Telephone | 804-229-3172
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MS. ANGELA REVERCOMB
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Credential | LPC
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Telephone | 804-955-8617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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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 | 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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