Provider Demographics
NPI:1801621768
Name:REVITALIZE FUNCTION LLC
Entity type:Organization
Organization Name:REVITALIZE FUNCTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:FIROVED
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MOT, OTR/L
Authorized Official - Phone:757-663-2056
Mailing Address - Street 1:712 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1623
Mailing Address - Country:US
Mailing Address - Phone:757-663-2056
Mailing Address - Fax:
Practice Address - Street 1:712 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1623
Practice Address - Country:US
Practice Address - Phone:757-663-2056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty