Provider Demographics
NPI: | 1356003628 |
---|---|
Name: | REVIVE & THRIVE MENTAL HEALTH, LLC |
Entity Type: | Organization |
Organization Name: | REVIVE & THRIVE MENTAL HEALTH, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KIMBERLEE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CRAIG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 316-201-6294 |
Mailing Address - Street 1: | 4013 N RIDGE RD STE 110 |
Mailing Address - Street 2: | |
Mailing Address - City: | WICHITA |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67205-8859 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 316-201-6294 |
Mailing Address - Fax: | 316-364-3020 |
Practice Address - Street 1: | 4013 N RIDGE RD STE 110 |
Practice Address - Street 2: | |
Practice Address - City: | WICHITA |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67205-8859 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-631-2454 |
Practice Address - Fax: | 316-247-6062 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-10-13 |
Last Update Date: | 2023-05-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 30004842030001 | Medicaid | |
KS | 30004830030002 | Medicaid | |
KS | 363LP0808X | Other | TAXONOMY |