Healthcare Provider Details

I. General information

NPI: 1881358455
Provider Name (Legal Business Name): REVIVE FAMILY COUNSELING, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8981 DANIELS CENTER DR STE 209
FORT MYERS FL
33912-0308
US

IV. Provider business mailing address

13852 ROSEWATER CT
FORT MYERS FL
33913-0057
US

V. Phone/Fax

Practice location:
  • Phone: 239-329-9264
  • Fax:
Mailing address:
  • Phone: 239-329-9264
  • 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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. EDITA HALL
Title or Position: LMFT
Credential: MS
Phone: 239-329-9264