MEDICARE: INTENT REVIVAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW.09925190	CO

General Provider Information

NPI Number	:	1457851925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENT REVIVAL

Provider Business Mailing Address
First Line	:	1817 ORCHARD PL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3323
Country	:	US
Telephone Number	:	970-624-9807
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 ORCHARD PL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3323
Country	:	US
Telephone Number	:	970-624-9807
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	FREYJA MAY
Credential	:	LCSW
Telephone Number	:	970-624-9807

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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