| Revival Road Therapy Pllc | |
|
121 N Main St Ste 201 Bloomington IL 61701-7619 | |
| (309) 204-6260 | |
| Not Available |
| Full Name | Revival Road Therapy Pllc |
|---|---|
| Speciality | Social Worker - Clinical |
| Location | 121 N Main St Ste 201, Bloomington, Illinois |
| Authorized Official Name and Position | Alexis Frantzen Crawford (OWNER/THERAPIST) |
| Authorized Official Contact | 3092046260 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Revival Road Therapy Pllc 121 N Main St Ste 201 Bloomington IL 61701-7619 Ph: (309) 204-6260 | Revival Road Therapy Pllc 121 N Main St Ste 201 Bloomington IL 61701-7619 Ph: (309) 204-6260 |
| NPI Number | 1518716992 |
|---|---|
| Provider Enumeration Date | 05/16/2024 |
| Last Update Date | 05/16/2024 |
| Certification Date | 05/10/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518716992 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
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