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: | OWNER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | EVANGELINE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | NEWSOM |
| 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: | 2024-07-07 |
| 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 | 30004830030002 | Medicaid | |
| KS | 363LP0808X | Other | TAXONOMY |
| KS | 30004842030001 | Medicaid |
