Provider Demographics
NPI:1558969840
Name:REVIVE COUNSELING AND WELLNESS CENTER
Entity Type:Organization
Organization Name:REVIVE COUNSELING AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-329-1253
Mailing Address - Street 1:36 KENNARD ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6013
Mailing Address - Country:US
Mailing Address - Phone:617-329-1253
Mailing Address - Fax:
Practice Address - Street 1:388 PLEASANT ST STE 201A
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8143
Practice Address - Country:US
Practice Address - Phone:617-329-1253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134532146OtherMENTAL HEALTH SERVICES
MA1134532146Medicaid