Provider Demographics
NPI:1619780145
Name:REVIVAL THERAPY SERVICES LLC
Entity type:Organization
Organization Name:REVIVAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACASSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-441-4622
Mailing Address - Street 1:1133 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-2502
Mailing Address - Country:US
Mailing Address - Phone:303-551-0017
Mailing Address - Fax:303-551-0117
Practice Address - Street 1:3520 AUSTIN BLUFFS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5756
Practice Address - Country:US
Practice Address - Phone:303-551-0117
Practice Address - Fax:303-551-0117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVIVAL THERAPY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty