Healthcare Provider Details

I. General information

NPI: 1508649955
Provider Name (Legal Business Name): REVITALIZE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6149 DELTONA BLVD
SPRING HILL FL
34606-1000
US

IV. Provider business mailing address

6149 DELTONA BLVD
SPRING HILL FL
34606-1000
US

V. Phone/Fax

Practice location:
  • Phone: 352-606-0323
  • Fax:
Mailing address:
  • Phone: 352-606-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DORY RICHARDS
Title or Position: OWNER
Credential: LMFT
Phone: 352-606-0323