Healthcare Provider Details

I. General information

NPI: 1457008591
Provider Name (Legal Business Name): REVIVAL THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 N PENNSYLVANIA ST
DENVER CO
80203-2502
US

IV. Provider business mailing address

1133 N PENNSYLVANIA ST
DENVER CO
80203-2502
US

V. Phone/Fax

Practice location:
  • Phone: 303-551-0117
  • Fax: 303-551-0117
Mailing address:
  • Phone: 303-551-0117
  • Fax: 303-551-0117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: SACHA LACASSE
Title or Position: DIRECTOR
Credential:
Phone: 720-441-4622