Provider Demographics
NPI:1518716992
Name:REVIVAL ROAD THERAPY PLLC
Entity type:Organization
Organization Name:REVIVAL ROAD THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANTZEN CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-204-6260
Mailing Address - Street 1:121 N MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7619
Mailing Address - Country:US
Mailing Address - Phone:309-204-6260
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7619
Practice Address - Country:US
Practice Address - Phone:309-204-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty