=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881096949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVISIONS COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2014
-----------------------------------------------------
Last Update Date | 09/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 LILY CACHE LN
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-481-6644
-----------------------------------------------------
Fax | 630-708-7632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 CANTERBURY LN #1996
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-0490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-481-6644
-----------------------------------------------------
Fax | 630-708-7632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. REGINA THOMAS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 630-481-6644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.008929
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------