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General NPI Number Information
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NPI Number | 1205675238
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Entity Type | Organization
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Legal Business Name | REVIVE WELLNESS CENTER
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Dates
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Enumeration Date | 05/20/2024
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | 226 N FRONT ST # 118
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City | WILMINGTON
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State | NC
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Zip | 28401-3920
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Country | US
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Telephone | 910-518-9837
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Fax |
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Provider Business Mailing Address
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Address Line | 103 ARABIAN CIR
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City | BEULAVILLE
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State | NC
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Zip | 28518-6791
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Country | US
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Telephone | 910-271-0415
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Fax |
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Authorized Official
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Title or Position | CLINICAL COUNSELOR
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Name | BREEANA KENNEDY
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Credential | LCMHC
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Telephone | 910-271-0415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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