Healthcare Provider Details

I. General information

NPI: 1093511891
Provider Name (Legal Business Name): REVIVAL BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 AFRICA RD
ALTON NH
03809-5105
US

IV. Provider business mailing address

PO BOX 552
ALTON NH
03809-0552
US

V. Phone/Fax

Practice location:
  • Phone: 603-716-5178
  • Fax:
Mailing address:
  • Phone: 603-716-5178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSICA LEE RIVET
Title or Position: OWNER
Credential: PMHNP-BC, MSN, APRN
Phone: 603-716-5178