Provider Demographics
NPI:1033237581
Name:REVILLE, JULIE D (MS CCCSLP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:D
Last Name:REVILLE
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHURCH ST
Mailing Address - Street 2:SUITE 4G
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4299
Mailing Address - Country:US
Mailing Address - Phone:802-734-0777
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST
Practice Address - Street 2:SUITE 4G
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4299
Practice Address - Country:US
Practice Address - Phone:802-734-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01038597235Z00000X
VT068-0000747101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4149910OtherMVP
00049731OtherBLUE CROSS BLUE SHIELD