Provider Demographics
NPI:1912443094
Name:REVIVE WELLNESS
Entity Type:Organization
Organization Name:REVIVE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:640-457-8542
Mailing Address - Street 1:119 HARRY STREET
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 HARRY ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428
Practice Address - Country:US
Practice Address - Phone:610-457-8542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW016642251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health