Provider Demographics
NPI:1134081862
Name:REVITALIZE SUPPORT SERVICES, LLC
Entity type:Organization
Organization Name:REVITALIZE SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR/PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRENERENETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-619-1222
Mailing Address - Street 1:4606 MORAVIA RUN WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3582
Mailing Address - Country:US
Mailing Address - Phone:443-619-1222
Mailing Address - Fax:443-619-1222
Practice Address - Street 1:4606 MORAVIA RUN WAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-3582
Practice Address - Country:US
Practice Address - Phone:443-619-1222
Practice Address - Fax:443-619-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services