Provider Demographics
NPI:1174801070
Name:REVITALIZED FAMILY MINISTRIES
Entity type:Organization
Organization Name:REVITALIZED FAMILY MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-812-2521
Mailing Address - Street 1:PO BOX 19797
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-0597
Mailing Address - Country:US
Mailing Address - Phone:410-812-2521
Mailing Address - Fax:
Practice Address - Street 1:310 DOCKSIDE CT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MD
Practice Address - Zip Code:21225-2935
Practice Address - Country:US
Practice Address - Phone:410-812-2521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health