Provider Demographics
NPI:1851057269
Name:REVITA THERAPY & WELLNESS
Entity Type:Organization
Organization Name:REVITA THERAPY & WELLNESS
Other - Org Name:RENEW THERAPY & WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:334-294-7341
Mailing Address - Street 1:2500 EASTERN BLVD UNIT 230938
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-3046
Mailing Address - Country:US
Mailing Address - Phone:334-676-1363
Mailing Address - Fax:
Practice Address - Street 1:2740 CENTRAL PKWY STE 2
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3243
Practice Address - Country:US
Practice Address - Phone:334-294-7341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty