Healthcare Provider Details

I. General information

NPI: 1699342832
Provider Name (Legal Business Name): REVIVE HEALING & WELLNESS INSTITUTE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 SIDNEY MARCUS BLVD NE UNIT 1412
ATLANTA GA
30324-3160
US

IV. Provider business mailing address

970 SIDNEY MARCUS BLVD NE UNIT 1412
ATLANTA GA
30324-3160
US

V. Phone/Fax

Practice location:
  • Phone: 404-500-9494
  • Fax:
Mailing address:
  • Phone: 404-500-9494
  • 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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA BAUMAN
Title or Position: PARTNER
Credential: LMFT
Phone: 509-985-8788