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General NPI Number Information
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NPI Number | 1801667621
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Entity Type | Organization
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Legal Business Name | REVERIE CREATIVE ARTS THERAPY SERVICES, PLLC
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Dates
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Enumeration Date | 01/10/2024
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 7000 E GENESEE ST STE D
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-1131
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Country | US
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Telephone | 315-783-8191
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Fax |
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Provider Business Mailing Address
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Address Line | 6494 COLTON RD
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City | LA FAYETTE
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State | NY
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Zip | 13084-9658
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Country | US
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Telephone | 315-783-8191
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Fax |
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Authorized Official
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Title or Position | THERAPIST/OWNER
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Name | MACKENZIE GILLETT GILLETT
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Credential | LCAT, ATR-BC
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Telephone | 315-783-8191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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