Provider Demographics
NPI:1306321567
Name:REVIVE COUNSELING SPOKANE, PLLC
Entity type:Organization
Organization Name:REVIVE COUNSELING SPOKANE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:509-413-2950
Mailing Address - Street 1:2222 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-4545
Mailing Address - Country:US
Mailing Address - Phone:509-413-2950
Mailing Address - Fax:509-241-1866
Practice Address - Street 1:2222 N MONROE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-4545
Practice Address - Country:US
Practice Address - Phone:509-413-2950
Practice Address - Fax:509-241-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225556483Medicaid
WA1679873368Medicaid
WA1700304920Medicaid
WA2079260Medicaid