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General NPI Number Information
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NPI Number | 1740152644
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Entity Type | Organization
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Legal Business Name | REVISIT PLAY, LLC
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Dates
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Enumeration Date | 09/19/2025
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Last Update Date | 09/19/2025
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Provider Practice Location Address
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Address Line | 1140 S MORTON ST
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City | BLOOMINGTON
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State | IN
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Zip | 47403-4744
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Country | US
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Telephone | 812-727-4922
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1424
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City | BLOOMINGTON
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State | IN
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Zip | 47402-1424
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Country | US
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Telephone | 812-727-4922
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Fax |
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Authorized Official
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Title or Position | RENDERING PROVIDER
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Name | WHITNEY SULLIVAN
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Credential | LCSW, RDT/BCT
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Telephone | 812-727-4922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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