Healthcare Provider Details

I. General information

NPI: 1154977064
Provider Name (Legal Business Name): REVIVE WELLNESS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 NARNIA WAY UNIT 102
LAND O LAKES FL
34638-7270
US

IV. Provider business mailing address

2647 NARNIA WAY UNIT 102
LAND O LAKES FL
34638-7270
US

V. Phone/Fax

Practice location:
  • Phone: 407-250-7831
  • Fax:
Mailing address:
  • Phone: 407-250-7831
  • 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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEIGHYA J RICHARD
Title or Position: OWNER/LICENSED PSYCHOTHERAPIST
Credential: LMHC
Phone: 407-250-7831