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General NPI Number Information
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NPI Number | 1538637277
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Entity Type | Organization
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Legal Business Name | REVEL LIVING LLC
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Dates
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Enumeration Date | 11/12/2018
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Last Update Date | 11/30/2020
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Provider Practice Location Address
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Address Line | 1740 RIDGE AVE STE 305
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City | EVANSTON
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State | IL
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Zip | 60201-5909
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Country | US
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Telephone | 312-899-6184
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Fax |
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Provider Business Mailing Address
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Address Line | 2619 CENTRAL ST APT 3
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City | EVANSTON
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State | IL
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Zip | 60201-6415
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Country | US
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Telephone | 619-952-8263
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | MARK VAUGHAN
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Credential | LMFT
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Telephone | 619-952-8263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children 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 | 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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