Provider Demographics
NPI:1508649955
Name:REVITALIZE LLC
Entity Type:Organization
Organization Name:REVITALIZE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:352-606-0323
Mailing Address - Street 1:6149 DELTONA BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1000
Mailing Address - Country:US
Mailing Address - Phone:352-606-0323
Mailing Address - Fax:
Practice Address - Street 1:6149 DELTONA BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1000
Practice Address - Country:US
Practice Address - Phone:352-606-0323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty