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General NPI Number Information
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NPI Number | 1528410610
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Entity Type | Organization
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Legal Business Name | REVIDAS LLC
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Dates
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Enumeration Date | 07/12/2016
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 108 GROVE STREET SUITE LL11
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City | WORCESTER
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State | MA
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Zip | 01605-2677
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Country | US
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Telephone | 508-304-7499
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Fax | 774-420-7255
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Provider Business Mailing Address
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Address Line | 108 GROVE STREET SUITE LL11
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City | WORCESTER
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State | MA
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Zip | 01605-2677
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Country | US
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Telephone | 508-304-7499
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Fax | 774-420-7255
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | MR. GEOFFREY CUSHNER
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Credential |
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Telephone | 508-304-7499
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 3875
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License Number State | MA
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