Provider Demographics
NPI:1457822462
Name:REVIVE THERAPY CENTER LLC
Entity type:Organization
Organization Name:REVIVE THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VON ERFFA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-252-6797
Mailing Address - Street 1:376 LOS RANCHOS RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6532
Mailing Address - Country:US
Mailing Address - Phone:505-252-6797
Mailing Address - Fax:
Practice Address - Street 1:7013 4TH ST NW STE C
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6639
Practice Address - Country:US
Practice Address - Phone:505-356-2200
Practice Address - Fax:844-272-7030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty