Provider Demographics
NPI:1548926801
Name:REVIVE BEHAVIORAL HEALTH AND WELLNESS LLC
Entity type:Organization
Organization Name:REVIVE BEHAVIORAL HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:308-850-4330
Mailing Address - Street 1:215 N WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-5961
Mailing Address - Country:US
Mailing Address - Phone:308-391-2280
Mailing Address - Fax:308-832-4803
Practice Address - Street 1:215 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-5961
Practice Address - Country:US
Practice Address - Phone:308-391-2280
Practice Address - Fax:308-832-4803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-11
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty