Provider Demographics
NPI:1093511891
Name:REVIVAL BEHAVIORAL HEALTH SERVICES
Entity type:Organization
Organization Name:REVIVAL BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RIVET
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, MSN, APRN
Authorized Official - Phone:603-716-5178
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:NH
Mailing Address - Zip Code:03809-0552
Mailing Address - Country:US
Mailing Address - Phone:603-716-5178
Mailing Address - Fax:
Practice Address - Street 1:235 AFRICA RD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:NH
Practice Address - Zip Code:03809-5105
Practice Address - Country:US
Practice Address - Phone:603-716-5178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health