Healthcare Provider Details

I. General information

NPI: 1083440440
Provider Name (Legal Business Name): TASHA REVOLUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 08/13/2025
Certification Date: 09/12/2024
Deactivation Date: 12/09/2024
Reactivation Date: 08/13/2025

III. Provider practice location address

555 S FLOYD ST
LOUISVILLE KY
40202-3822
US

IV. Provider business mailing address

555 S FLOYD ST
LOUISVILLE KY
40202-3822
US

V. Phone/Fax

Practice location:
  • Phone: 502-533-3990
  • Fax:
Mailing address:
  • Phone: 502-533-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1163808
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: