Healthcare Provider Details

I. General information

NPI: 1609330463
Provider Name (Legal Business Name): REVIVE THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 WOODLEAF RD APT 7H
SALISBURY NC
28147-1181
US

IV. Provider business mailing address

2205 WOODLEAF RD APT 7H
SALISBURY NC
28147-1181
US

V. Phone/Fax

Practice location:
  • Phone: 252-762-9788
  • Fax:
Mailing address:
  • Phone: 252-762-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LEANDRA SALLEY
Title or Position: PARTNER
Credential: MSW
Phone: 252-762-9788