Healthcare Provider Details

I. General information

NPI: 1295644367
Provider Name (Legal Business Name): REVIVE HOPE & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WESTMONT DR
WATERBURY CT
06708-2400
US

IV. Provider business mailing address

544 STRAITS TPKE STE 3
WATERTOWN CT
06795-3340
US

V. Phone/Fax

Practice location:
  • Phone: 203-508-5069
  • Fax:
Mailing address:
  • Phone: 203-723-3468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. VENESA WHITE
Title or Position: OWNER/ COUNCELOR
Credential: LPC
Phone: 203-508-5069