Provider Demographics
NPI:1457919516
Name:REVIBE THERAPY PLLC
Entity Type:Organization
Organization Name:REVIBE THERAPY PLLC
Other - Org Name:REVIBE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HYPNOTHERAPIST/ PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:407-801-2191
Mailing Address - Street 1:11901 LANDING POINT LOOP
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5904
Mailing Address - Country:US
Mailing Address - Phone:407-801-2191
Mailing Address - Fax:
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7593
Practice Address - Country:US
Practice Address - Phone:407-801-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1629635073Medicaid