Provider Demographics
NPI:1043229651
Name:REVELATION THERAPY HEALTH SERVICES
Entity Type:Organization
Organization Name:REVELATION THERAPY HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIBISAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NISBETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-452-6086
Mailing Address - Street 1:840 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-1316
Mailing Address - Country:US
Mailing Address - Phone:862-452-6086
Mailing Address - Fax:973-374-4494
Practice Address - Street 1:115 EVERGREEN PL
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2006
Practice Address - Country:US
Practice Address - Phone:862-452-6086
Practice Address - Fax:973-677-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ401OA01008800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084358Medicare ID - Type Unspecified