Provider Demographics
NPI:1003797176
Name:REVIVE CLINIC LLC
Entity type:Organization
Organization Name:REVIVE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:443-328-4810
Mailing Address - Street 1:5457 TWIN KNOLLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3296
Mailing Address - Country:US
Mailing Address - Phone:443-328-4810
Mailing Address - Fax:269-210-2598
Practice Address - Street 1:10101 TWIN RIVERS ROAD APT 401
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:443-328-4810
Practice Address - Fax:269-210-2598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-08
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty