Healthcare Provider Details

I. General information

NPI: 1427654193
Provider Name (Legal Business Name): REVIVE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 HOLLY AVE NE BLDG 4
ALBUQUERQUE NM
87122-2969
US

IV. Provider business mailing address

8409 JOSEPH SHARP ST NE
ALBUQUERQUE NM
87122-2810
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-6624
  • Fax:
Mailing address:
  • Phone: 505-720-6624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ANGELA ROMERO
Title or Position: THERAPIST
Credential:
Phone: 505-720-6624