Provider Demographics
NPI:1013416783
Name:REVELL, THERESA MARIE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:REVELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6539 MAN O WAR TRL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-1615
Mailing Address - Country:US
Mailing Address - Phone:850-597-5128
Mailing Address - Fax:
Practice Address - Street 1:6539 MAN O WAR TRL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-1615
Practice Address - Country:US
Practice Address - Phone:850-597-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA28686225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist