Healthcare Provider Details

I. General information

NPI: 1972466282
Provider Name (Legal Business Name): REVIVE COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11535 PARK WOODS CIR STE C
ALPHARETTA GA
30005-4490
US

IV. Provider business mailing address

11535 PARK WOODS CIR STE C
ALPHARETTA GA
30005-4490
US

V. Phone/Fax

Practice location:
  • Phone: 833-221-4169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: AZAR MEMARZADEH
Title or Position: PRESIDENT
Credential:
Phone: 833-221-4169