Healthcare Provider Details

I. General information

NPI: 1366325466
Provider Name (Legal Business Name): REVIVE AND THRIVE COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 PLAZA AMERICA DR STE 2000
RESTON VA
20190-4743
US

IV. Provider business mailing address

8500 LAKINHURST LN
SPRINGFIELD VA
22152-1727
US

V. Phone/Fax

Practice location:
  • Phone: 703-829-6554
  • Fax:
Mailing address:
  • Phone: 703-829-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOSE DIAZ
Title or Position: OWNER
Credential: LPC
Phone: 703-829-6554