Healthcare Provider Details

I. General information

NPI: 1780446476
Provider Name (Legal Business Name): REVIVE THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 LOGAN AVE
BELVIDERE IL
61008-6412
US

IV. Provider business mailing address

1818 LOGAN AVE
BELVIDERE IL
61008-6412
US

V. Phone/Fax

Practice location:
  • Phone: 815-575-9887
  • Fax: 815-534-1437
Mailing address:
  • Phone: 815-575-9887
  • Fax: 815-534-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. SHELLI POLLARD
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 815-575-9887