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General NPI Number Information
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NPI Number | 1336715622
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Entity Type | Organization
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Legal Business Name | REVIVAL THERAPEUTIC SERVICES LLC
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 2885 LINDALE MOUNT HOLLY RD
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City | AMELIA
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State | OH
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Zip | 45102-9707
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Country | US
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Telephone | 513-401-4038
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Fax |
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Provider Business Mailing Address
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Address Line | 2885 LINDALE MOUNT HOLLY RD
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City | AMELIA
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State | OH
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Zip | 45102-9707
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RYAN HALL
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Credential | LISW
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Telephone | 513-401-4038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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