Provider Demographics
NPI:1669167227
Name:REVITCH, SOPHIE A (BCBA)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:A
Last Name:REVITCH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:A
Other - Last Name:REVITCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2500 ARAPAHOE AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6752
Mailing Address - Country:US
Mailing Address - Phone:877-910-6538
Mailing Address - Fax:
Practice Address - Street 1:2441 S VRAIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80219-5100
Practice Address - Country:US
Practice Address - Phone:802-522-6829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-23-64850103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst