MEDICARE: REVIIVE THERAPY SERVICES, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1437935061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIIVE THERAPY SERVICES, PLLC

Provider Business Mailing Address
First Line	:	2201 RACQUET CLUB CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-3724
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N WATSON RD STE 201
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-6120
Country	:	US
Telephone Number	:	469-558-0443
Fax Number	:	817-987-1288

Authorized Official
Title or Position	:	OWNER
Name	:	EBONII NELSON
Credential	:
Telephone Number	:	469-939-6827

Provider Enumeration Date	:	09/08/2023
Last Update Date	:	09/08/2023

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