=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013535145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITALIZE CONSULTING GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S MIDLAND BLVD
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-977-3077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 S MIDLAND BLVD
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-997-3077
-----------------------------------------------------
Fax | 208-997-3077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | LAURA L SANDER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 208-997-3077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------