Provider Demographics
NPI:1336715622
Name:REVIVAL THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:REVIVAL THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:513-401-4038
Mailing Address - Street 1:2885 LINDALE MOUNT HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-9707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2885 LINDALE MOUNT HOLLY RD
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-9707
Practice Address - Country:US
Practice Address - Phone:513-401-4038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty