Organization
REVIVE ATHLETICS, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MATTHEW HARRELL (EXECUTIVE DIRECTOR)
(770) 899-8187
Entity
Organization
Contact information
Practice address
460 BOURNE DRIVE, SMYRNA, GA 30082
(770) 899-8187
Mailing address
2916 LONESOME PINE LANE, ATLANTA, GA 30339-4114
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Enumeration date
10/15/2010
Last updated
10/15/2010
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