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General NPI Number Information
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NPI Number | 1407515620
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Entity Type | Organization
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Legal Business Name | REVIVAL COLLABORATIVE LLC
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Dates
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Enumeration Date | 12/15/2021
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 3700 MEDICAL CENTER PKWY
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City | BENTONVILLE
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State | AR
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Zip | 72712-3222
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Country | US
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Telephone | 479-721-2110
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Fax |
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Provider Business Mailing Address
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Address Line | 3202 SW HAZELNUT AVE
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City | BENTONVILLE
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State | AR
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Zip | 72713-3195
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Country | US
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Telephone | 479-721-2110
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ZACH S HEDGES
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Credential | LPC
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Telephone | 479-721-2110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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