=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457174344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE PSYCHIATRY & WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 MORELAND ST APT 3
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-1483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-294-9094
-----------------------------------------------------
Fax | 844-927-4990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 MORELAND ST APT 3
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-1483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 844-927-4990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHIATRIC NP
-----------------------------------------------------
Name | RHIANNA CANDIDO
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 617-294-9094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------