Provider Demographics
NPI:1215749114
Name:RESTORATION TRANSFORMATION
Entity type:Organization
Organization Name:RESTORATION TRANSFORMATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-747-0181
Mailing Address - Street 1:10355 PARADISE BLVD APT 704
Mailing Address - Street 2:
Mailing Address - City:TREASURE ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33706-3132
Mailing Address - Country:US
Mailing Address - Phone:580-747-0181
Mailing Address - Fax:
Practice Address - Street 1:235 PELICAN PL UNIT 3
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-7317
Practice Address - Country:US
Practice Address - Phone:580-747-0181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-27
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty