Revive Athletics, Inc

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

Legal business name

REVIVE ATHLETICS, INC

Practice address

460 Bourne Drive
Smyrna, GA 30082

Phone

(770) 899-8187

NPI assigned

Oct 15, 2010

Organization subpart

No

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

Authorized official

Name

Matthew Harrell

Title

Executive Director

Phone

(770) 899-8187

Specialties & licenses 2

Addresses

Locations

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

{
    "created_epoch": "1287100800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1287100800000",
    "number": "1487964193",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2916 LONESOME PINE LANE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303394114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "460 BOURNE DRIVE",
            "city": "SMYRNA",
            "state": "GA",
            "postal_code": "30082",
            "telephone_number": "770-899-8187"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE ATHLETICS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-10-15",
        "last_updated": "2010-10-15",
        "status": "A",
        "authorized_official_last_name": "HARRELL",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "770-899-8187"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Speech-Language Pathologist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Providers in Smyrna, GA by specialty
• Speech-Language Pathologist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.