Provider Demographics
NPI:1457008591
Name:REVIVAL THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:REVIVAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACASSE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:720-441-4622
Mailing Address - Street 1:1069 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-4544
Mailing Address - Country:US
Mailing Address - Phone:720-441-4622
Mailing Address - Fax:
Practice Address - Street 1:2021 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3840
Practice Address - Country:US
Practice Address - Phone:720-441-4622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty