Healthcare Provider Details

I. General information

NPI: 1609702422
Provider Name (Legal Business Name): BETHESDA REVIVE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W KENNEDY BLVD STE 310
TAMPA FL
33609-2290
US

IV. Provider business mailing address

4100 W KENNEDY BLVD STE 310
TAMPA FL
33609-2290
US

V. Phone/Fax

Practice location:
  • Phone: 813-535-4594
  • Fax: 813-706-3723
Mailing address:
  • Phone: 813-535-4594
  • Fax: 813-706-3723

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. BARBARA MARGARITA SOSA BALADRON
Title or Position: PSYCHOTHERAPIST
Credential: LMHC
Phone: 813-535-4594