Healthcare Provider Details

I. General information

NPI: 1699591271
Provider Name (Legal Business Name): REVIVE BEHAVIORAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 CHARLES PARTIN DR
PARRISH FL
34219-1243
US

IV. Provider business mailing address

4715 CHARLES PARTIN DR
PARRISH FL
34219-1243
US

V. Phone/Fax

Practice location:
  • Phone: 857-500-3381
  • Fax:
Mailing address:
  • Phone: 857-500-3381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: KEVIN DOUGLAS KENT
Title or Position: BCBA
Credential: M.A.
Phone: 857-500-3381