Provider Demographics
NPI:1205202413
Name:REVIS, JOHNNA (PTA)
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:REVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5768 HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:GRAY COURT
Mailing Address - State:SC
Mailing Address - Zip Code:29645-6764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5768 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:GRAY COURT
Practice Address - State:SC
Practice Address - Zip Code:29645-6764
Practice Address - Country:US
Practice Address - Phone:864-872-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1771320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities