Provider Demographics
NPI:1780446476
Name:REVIVE THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:REVIVE THERAPY AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-575-9887
Mailing Address - Street 1:1818 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-6412
Mailing Address - Country:US
Mailing Address - Phone:815-575-9887
Mailing Address - Fax:815-534-1437
Practice Address - Street 1:1818 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-6412
Practice Address - Country:US
Practice Address - Phone:815-575-9887
Practice Address - Fax:815-534-1437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty