Healthcare Provider Details

I. General information

NPI: 1063324580
Provider Name (Legal Business Name): REVIVIR PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 BUTLER ST
EASTON PA
18042-4712
US

IV. Provider business mailing address

212 S 1ST ST
BANGOR PA
18013-2640
US

V. Phone/Fax

Practice location:
  • Phone: 484-748-0484
  • Fax: 551-202-7648
Mailing address:
  • Phone: 484-748-0484
  • Fax: 551-202-7648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEBORA MONSERRAT
Title or Position: OWNER
Credential: CRNP-BC
Phone: 484-748-0484