Provider Demographics
NPI:1427301092
Name:JOURNEY REVEALED
Entity type:Organization
Organization Name:JOURNEY REVEALED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZE-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:803-431-0734
Mailing Address - Street 1:44429 ORIOLE DR
Mailing Address - Street 2:UNIT 101
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 FIRST BAXTER XING
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8948
Practice Address - Country:US
Practice Address - Phone:803-431-0734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty