Provider Demographics
NPI:1073347605
Name:REVIVE COUNSELING LLC
Entity type:Organization
Organization Name:REVIVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUETTNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-365-6421
Mailing Address - Street 1:5830 LOOKOUT VW
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63016-1916
Mailing Address - Country:US
Mailing Address - Phone:314-365-6421
Mailing Address - Fax:
Practice Address - Street 1:9666 OLIVE BLVD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3026
Practice Address - Country:US
Practice Address - Phone:314-365-6421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-27
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty