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General NPI Number Information
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NPI Number | 1619638905
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Entity Type | Organization
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Legal Business Name | REVOLUTION YOUTH INC
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Dates
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Enumeration Date | 01/07/2022
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 95 COLLEGE ST
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City | BURLINGTON
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State | VT
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Zip | 05401-8426
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Country | US
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Telephone | 207-812-6070
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Fax |
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Provider Business Mailing Address
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Address Line | 95 COLLEGE ST
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City | BURLINGTON
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State | VT
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Zip | 05401-8426
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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 | DIRECTOR OF CLINICAL SERVICES
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Name | SAVANNAH LORD
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Credential | LICSW, LADC
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Telephone | 207-812-6070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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