Provider Demographics
NPI:1699537944
Name:REVIVE COUNSELING AND WELLNESS SERVICES
Entity type:Organization
Organization Name:REVIVE COUNSELING AND WELLNESS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:205-246-1656
Mailing Address - Street 1:1105 SOUTHVIEW LN STE 103-115
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-6390
Mailing Address - Country:US
Mailing Address - Phone:205-246-1656
Mailing Address - Fax:
Practice Address - Street 1:2615 6TH ST STE 8
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1727
Practice Address - Country:US
Practice Address - Phone:205-246-1656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty