Provider Demographics
NPI:1851070882
Name:REVIVE WELLCO
Entity type:Organization
Organization Name:REVIVE WELLCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHALOW
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:501-318-3760
Mailing Address - Street 1:919 TINY TOWN RD
Mailing Address - Street 2:SUITE B #2021
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-7660
Mailing Address - Country:US
Mailing Address - Phone:501-318-3760
Mailing Address - Fax:
Practice Address - Street 1:518 LATHAM CT.
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:501-318-3760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty