=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457822462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE THERAPY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7013 4TH ST NW STE C
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-6639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-356-2200
-----------------------------------------------------
Fax | 844-272-7030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 376 LOS RANCHOS RD NW
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-6532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-252-6797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | SALLY VON ERFFA
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 505-252-6797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------