Provider Demographics
NPI:1437871845
Name:REVIVE COUNSELING AND COACHING LLC
Entity Type:Organization
Organization Name:REVIVE COUNSELING AND COACHING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:HAWKINS-JACK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:989-715-4404
Mailing Address - Street 1:224 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 JOHN SIMS PKWY E STE B
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2202
Practice Address - Country:US
Practice Address - Phone:989-715-4404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619233566OtherINDIVIDUAL NPI