MEDICARE: REVIVAL THERAPY SERVICES LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1619780145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVAL THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	1133 N PENNSYLVANIA ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203-2502
Country	:	US
Telephone Number	:	303-551-0017
Fax Number	:	303-551-0117

Provider Business Practice Location Address
First Line	:	3520 AUSTIN BLUFFS PKWY STE 101
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-5756
Country	:	US
Telephone Number	:	303-551-0117
Fax Number	:	303-551-0117

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	SACHA LACASSE
Credential	:
Telephone Number	:	720-441-4622

Provider Enumeration Date	:	01/29/2025
Last Update Date	:	01/29/2025

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