1225472632 NPI number — REVEIVE YOUTH AND FAMILY SERVICES

Table of content: (NPI 1225472632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225472632 NPI number — REVEIVE YOUTH AND FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVEIVE YOUTH AND FAMILY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225472632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2518 N17TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-915-2637
Provider Business Mailing Address Fax Number:
414-810-1567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2518 N 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53206-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-915-2637
Provider Business Practice Location Address Fax Number:
414-810-1567
Provider Enumeration Date:
04/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLAIN
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
414-763-6603

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  8035461 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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