Provider Demographics
NPI:1700227618
Name:REVIVE HOLISTIC PSYCHOLOGY & WELLNESS CENTER
Entity type:Organization
Organization Name:REVIVE HOLISTIC PSYCHOLOGY & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSY
Authorized Official - Phone:787-562-6500
Mailing Address - Street 1:570 LA MANCHA MANS. CIUDAD JARDIN
Mailing Address - Street 2:
Mailing Address - City:CAUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-1430
Mailing Address - Country:US
Mailing Address - Phone:787-562-6500
Mailing Address - Fax:
Practice Address - Street 1:169 BUTARE AVE #1
Practice Address - Street 2:PLAZA REAL 207
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-562-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR005152103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty