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General NPI Number Information
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NPI Number | 1629901442
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Entity Type | Organization
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Legal Business Name | REVIVE INTEGRATED CARE, LLC
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Dates
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Enumeration Date | 06/03/2026
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Last Update Date | 06/03/2026
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Provider Practice Location Address
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Address Line | 208 COLE AVE
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City | MONROE
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State | LA
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Zip | 71203-3814
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Country | US
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Telephone | 318-791-1274
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Fax |
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Provider Business Mailing Address
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Address Line | 208 COLE AVE
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City | MONROE
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State | LA
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Zip | 71203-3814
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Country | US
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Telephone | 318-791-1274
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | LYNETTA GIPSON
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Credential | RN
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Telephone | 318-791-1274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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