Life Revival LLC

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

LIFE REVIVAL LLC

Practice address

6404 Roosevelt Blvd
Philadelphia, PA 19149-2943

Phone

(267) 577-7747

NPI assigned

May 26, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Daniel Lee, PSYD

Title

Director

Phone

(267) 259-4558

Specialties & licenses 15

Addresses

Other names 1

• Life Revival, LLC Other name

Medicare fee-for-service enrollment

Enrolled in PA

Enrollment records 1

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Abayomi O Ige, M.D.

  • Psychiatry Physician
  • Philadelphia, PA
  • NPI 1184620130
  Medicare reassignment NPD
• Kathleen Neil, MSN, PMHNP-BC

  • Psychiatric/Mental Health Nurse Practitioner
  • Philadelphia, PA
  • NPI 1861247876
  Medicare reassignment NPD
• Douglas Faxon, Jr., MS

  • Mental Health Counselor
  • Philadelphia, PA
  • NPI 1457863276
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1685059200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739232000000",
    "number": "1023701067",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6404 ROOSEVELT BLVD",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191492943"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6404 ROOSEVELT BLVD",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191492943",
            "telephone_number": "267-577-7747"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFE REVIVAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-05-26",
        "last_updated": "2025-02-11",
        "certification_date": "2025-02-11",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "267-259-4558",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": null,
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            "primary": false
        },
        {
            "code": "103TF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Family",
            "state": null,
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            "primary": false
        },
        {
            "code": "103TP0814X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Psychoanalysis",
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        },
        {
            "code": "103TP2701X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Group Psychotherapy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
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            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Life Revival, LLC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Community/Behavioral Health Agency in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Community/Behavioral Health Agency in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.