MEDICARE: REVIVE TO THRIVE THERAPIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1578260717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE TO THRIVE THERAPIES

Provider Business Mailing Address
First Line	:	3450 E LAKE RD STE 307
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-2411
Country	:	US
Telephone Number	:	727-238-5821
Fax Number	:	833-331-2658

Provider Business Practice Location Address
First Line	:	3450 E LAKE RD STE 307
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34685-2411
Country	:	US
Telephone Number	:	727-238-5821
Fax Number	:	833-331-2658

Authorized Official
Title or Position	:	COO
Name	:	DEBRA BROWN
Credential	:	PHD
Telephone Number	:	727-238-5821

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	01/08/2024

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