=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851057269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITA THERAPY & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2021
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2740 CENTRAL PKWY STE 2
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-294-7341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 EASTERN BLVD UNIT 230938
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36123-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-676-1363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CANDYCE ANDERSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 334-294-7341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------