Provider Demographics
NPI:1215780101
Name:REVIVE WELLNESS LLC
Entity type:Organization
Organization Name:REVIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO/OWNER / THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-219-5057
Mailing Address - Street 1:802 BACON ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4534
Mailing Address - Country:US
Mailing Address - Phone:309-219-5057
Mailing Address - Fax:
Practice Address - Street 1:802 BACON ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-4534
Practice Address - Country:US
Practice Address - Phone:309-219-5057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty