Healthcare Provider Details

I. General information

NPI: 1851057269
Provider Name (Legal Business Name): REVITA THERAPY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 CENTRAL PKWY STE 2
MONTGOMERY AL
36106-3243
US

IV. Provider business mailing address

2500 EASTERN BLVD UNIT 230938
MONTGOMERY AL
36123-3046
US

V. Phone/Fax

Practice location:
  • Phone: 334-294-7341
  • Fax:
Mailing address:
  • Phone: 334-676-1363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. CANDYCE ANDERSON
Title or Position: OWNER
Credential: LPC
Phone: 334-294-7341