| Refined Therapy Group, Llc | |
|
1403 43rd Ave Ste D Gulfport MS 39501-2545 | |
| (601) 215-5545 | |
| Not Available |
| Full Name | Refined Therapy Group, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1403 43rd Ave Ste D, Gulfport, Mississippi |
| Authorized Official Name and Position | Riva Cornelius (OWNER) |
| Authorized Official Contact | 2284939141 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Refined Therapy Group, Llc 2012 W Second St Apt 257 Long Beach MS 39560-5513 Ph: (228) 493-9141 | Refined Therapy Group, Llc 1403 43rd Ave Ste D Gulfport MS 39501-2545 Ph: (601) 215-5545 |
| NPI Number | 1003555079 |
|---|---|
| Provider Enumeration Date | 05/30/2022 |
| Last Update Date | 01/21/2023 |
| Certification Date | 01/21/2023 |
| Medicare PECOS PAC ID | 3779959176 |
|---|---|
| Medicare Enrollment ID | O20221025003271 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003555079 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Riva Cornelius |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1881287118 PECOS PAC ID: 3870987159 Enrollment ID: I20220302002327 |
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