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General NPI Number Information
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NPI Number | 1184447955
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Entity Type | Organization
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Legal Business Name | PSYCH REVIVAL THERAPY LLC
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Dates
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Enumeration Date | 11/01/2024
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 1675 E SEMINOLE ST
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City | SPRINGFIELD
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State | MO
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Zip | 65804-2490
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Country | US
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Telephone | 970-208-7791
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Fax |
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Provider Business Mailing Address
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Address Line | 3097 N DICKERSON AVE
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City | SPRINGFIELD
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State | MO
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Zip | 65803-1267
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Country | US
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Telephone | 970-208-7791
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | NICHOLE SPROWSO
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Credential | LCSW
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Telephone | 970-208-7791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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