Provider Demographics
NPI:1366310112
Name:MENTAL HEALTH PRO PA REVIVED WELLNESS
Entity type:Organization
Organization Name:MENTAL HEALTH PRO PA REVIVED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ENEYI
Authorized Official - Last Name:ABOLARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-300-9424
Mailing Address - Street 1:7475 CALLAGHAN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2969
Mailing Address - Country:US
Mailing Address - Phone:210-903-3383
Mailing Address - Fax:210-544-5194
Practice Address - Street 1:7475 CALLAGHAN RD STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2934
Practice Address - Country:US
Practice Address - Phone:210-903-3383
Practice Address - Fax:210-544-5194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-24
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty