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General NPI Number Information
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NPI Number | 1548926801
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Entity Type | Organization
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Legal Business Name | REVIVE BEHAVIORAL HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 11/11/2021
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 215 N WHEELER AVE
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City | GRAND ISLAND
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State | NE
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Zip | 68801-5961
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Country | US
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Telephone | 308-391-2280
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Fax | 308-832-4803
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Provider Business Mailing Address
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Address Line | 215 N WHEELER AVE
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City | GRAND ISLAND
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State | NE
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Zip | 68801-5961
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Country | US
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Telephone | 308-391-2280
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Fax | 308-832-4803
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Authorized Official
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Title or Position | OWNER
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Name | ANGELA LYON
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Credential | LICSW
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Telephone | 308-850-4330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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