Healthcare Provider Details

I. General information

NPI: 1942117155
Provider Name (Legal Business Name): REVIVAL WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 FALL CREEK RD STE 102
INDIANAPOLIS IN
46256-9406
US

IV. Provider business mailing address

7264 S WOODROW DR
PENDLETON IN
46064-9102
US

V. Phone/Fax

Practice location:
  • Phone: 814-282-5489
  • Fax:
Mailing address:
  • Phone: 814-282-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KAYLEE DURNELL
Title or Position: OWNER
Credential: LCSW
Phone: 814-282-5489