Provider Demographics
NPI:1639885171
Name:REVIVE WELLNESS
Entity Type:Organization
Organization Name:REVIVE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:SHOCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:218-289-7023
Mailing Address - Street 1:116 W ROBERT ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1709
Mailing Address - Country:US
Mailing Address - Phone:218-289-7023
Mailing Address - Fax:
Practice Address - Street 1:116 W ROBERT ST STE 2B
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1709
Practice Address - Country:US
Practice Address - Phone:218-289-7023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)