=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326731829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE REVIVE COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2023
-----------------------------------------------------
Last Update Date | 05/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64501 232ND ST
-----------------------------------------------------
City | GLENWOOD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51534-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-660-7454
-----------------------------------------------------
Fax | 712-355-5234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 N 29TH ST
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51501-0755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-660-7454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | ANGELA MARIE CLARK
-----------------------------------------------------
Credential | PLMHP
-----------------------------------------------------
Telephone | 402-660-7454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------