Provider Demographics
NPI:1306523568
Name:REVAMP CREATIVE, LLC
Entity type:Organization
Organization Name:REVAMP CREATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:PETRA
Authorized Official - Last Name:DAVISSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:503-929-7750
Mailing Address - Street 1:63 NE THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3741
Mailing Address - Country:US
Mailing Address - Phone:503-929-7750
Mailing Address - Fax:
Practice Address - Street 1:4037 NE TILLAMOOK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5341
Practice Address - Country:US
Practice Address - Phone:503-929-7750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty