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General NPI Number Information
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NPI Number | 1093511891
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Entity Type | Organization
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Legal Business Name | REVIVAL BEHAVIORAL HEALTH SERVICES
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Dates
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Enumeration Date | 02/21/2025
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Last Update Date | 02/21/2025
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Provider Practice Location Address
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Address Line | 235 AFRICA RD
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City | ALTON
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State | NH
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Zip | 03809-5105
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Country | US
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Telephone | 603-716-5178
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 552
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City | ALTON
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State | NH
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Zip | 03809-0552
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Country | US
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Telephone | 603-716-5178
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA LEE RIVET
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Credential | PMHNP-BC, MSN, APRN
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Telephone | 603-716-5178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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