Healthcare Provider Details

I. General information

NPI: 1346937588
Provider Name (Legal Business Name): REVIVE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S BAY DR
GILBERT AZ
85233-6539
US

IV. Provider business mailing address

510 S BAY DR
GILBERT AZ
85233-6539
US

V. Phone/Fax

Practice location:
  • Phone: 913-904-8565
  • Fax:
Mailing address:
  • Phone: 913-904-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TANJA NICOLE MUNDT
Title or Position: CEO
Credential: LPC-S
Phone: 913-904-8565