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General NPI Number Information
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NPI Number | 1457008591
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Entity Type | Organization
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Legal Business Name | REVIVAL THERAPY SERVICES LLC
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Dates
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Enumeration Date | 03/08/2022
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Last Update Date | 10/25/2024
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Provider Practice Location Address
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Address Line | 1133 N PENNSYLVANIA ST
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City | DENVER
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State | CO
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Zip | 80203-2502
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Country | US
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Telephone | 303-551-0117
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Fax | 303-551-0117
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Provider Business Mailing Address
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Address Line | 1133 N PENNSYLVANIA ST
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City | DENVER
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State | CO
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Zip | 80203-2502
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Country | US
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Telephone | 303-551-0117
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Fax | 303-551-0117
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Authorized Official
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Title or Position | DIRECTOR
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Name | SACHA LACASSE
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Credential |
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Telephone | 720-441-4622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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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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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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