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General NPI Number Information
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NPI Number | 1851070882
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Entity Type | Organization
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Legal Business Name | REVIVE WELLCO
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Dates
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Enumeration Date | 07/17/2023
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Last Update Date | 10/18/2024
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Provider Practice Location Address
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Address Line | 518 LATHAM CT.
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City | CLARKSVILLE
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State | TN
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Zip | 37043
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Country | US
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Telephone | 501-318-3760
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Fax |
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Provider Business Mailing Address
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Address Line | 919 TINY TOWN RD SUITE B #2021
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City | CLARKSVILLE
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State | TN
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Zip | 37042-7660
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Country | US
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Telephone | 501-318-3760
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JENNIFER SCHALOW
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Credential | LPC-S
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Telephone | 501-318-3760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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