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General NPI Number Information
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NPI Number | 1952062770
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Entity Type | Organization
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Legal Business Name | REVAMPED RELATIONSHIPS
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Dates
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Enumeration Date | 01/04/2022
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Last Update Date | 07/09/2025
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Provider Practice Location Address
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Address Line | 631 N CARROLL PKWY APT 209
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City | GLENWOOD
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State | IL
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Zip | 60425-1161
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Country | US
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Telephone | 708-637-6760
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Fax |
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Provider Business Mailing Address
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Address Line | 631 N CARROLL PKWY APT 209
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City | GLENWOOD
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State | IL
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Zip | 60425-1161
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Country | US
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Telephone | 773-517-3504
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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 | JALISSA REYNOLDS
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Credential | LCPC
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Telephone | 773-517-3504
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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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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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