Provider Demographics
NPI:1073284121
Name:MORGAN, REVENDA JA-MELL (LMBT)
Entity Type:Individual
Prefix:
First Name:REVENDA
Middle Name:JA-MELL
Last Name:MORGAN
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:REVENDA
Other - Middle Name:JA-MELL
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NCBTMB CE PROVIDER
Mailing Address - Street 1:1350 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1433
Mailing Address - Country:US
Mailing Address - Phone:336-251-4848
Mailing Address - Fax:
Practice Address - Street 1:1350 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1433
Practice Address - Country:US
Practice Address - Phone:336-251-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08881225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist