Provider Demographics
NPI:1568197556
Name:REVIVE 180 LLC
Entity Type:Organization
Organization Name:REVIVE 180 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PASHIA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:573-438-9800
Mailing Address - Street 1:10071 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-2040
Mailing Address - Country:US
Mailing Address - Phone:573-438-9800
Mailing Address - Fax:573-240-9916
Practice Address - Street 1:10071 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-2040
Practice Address - Country:US
Practice Address - Phone:573-438-9800
Practice Address - Fax:573-240-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490084654Medicaid