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General NPI Number Information
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NPI Number | 1821778788
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Entity Type | Organization
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Legal Business Name | REVIVE 3.23, LLC
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Dates
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Enumeration Date | 07/24/2023
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Last Update Date | 07/24/2023
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Provider Practice Location Address
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Address Line | 200 BEACON PKWY W STE 101
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City | BIRMINGHAM
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State | AL
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Zip | 35209-3102
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Country | US
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Telephone | 205-215-4211
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Fax |
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Provider Business Mailing Address
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Address Line | 301 8TH PL
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City | PLEASANT GROVE
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State | AL
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Zip | 35127-1829
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Country | US
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Telephone | 205-215-4211
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JOI IMAN GRESHAM
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Credential | MSW, LICSW
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Telephone | 205-215-4211
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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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