Provider Demographics
NPI:1487135984
Name:REVELATION TREE COUNSELING AND WELLNESS, LLC
Entity type:Organization
Organization Name:REVELATION TREE COUNSELING AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC MHSP, NCC
Authorized Official - Phone:901-586-6317
Mailing Address - Street 1:3865 BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:MUNFORD
Mailing Address - State:TN
Mailing Address - Zip Code:38058-4277
Mailing Address - Country:US
Mailing Address - Phone:901-586-6317
Mailing Address - Fax:901-476-5799
Practice Address - Street 1:3865 BEAVER RD
Practice Address - Street 2:
Practice Address - City:MUNFORD
Practice Address - State:TN
Practice Address - Zip Code:38058
Practice Address - Country:US
Practice Address - Phone:901-586-6317
Practice Address - Fax:901-296-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty