Provider Demographics
NPI:1841639556
Name:REVISION STUDIO LLC THERAPY AND COUNSELING SERVICES
Entity type:Organization
Organization Name:REVISION STUDIO LLC THERAPY AND COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:CROEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-274-4284
Mailing Address - Street 1:P.O. BOX 172
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-9203
Mailing Address - Country:US
Mailing Address - Phone:203-274-4284
Mailing Address - Fax:
Practice Address - Street 1:3 WEST END AVENUE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-9203
Practice Address - Country:US
Practice Address - Phone:203-274-4284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0042691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
800003783Medicare PIN