Provider Demographics
NPI:1245580976
Name:REVELLO, PATRICK JOHN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JOHN
Last Name:REVELLO
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1971
Mailing Address - Country:US
Mailing Address - Phone:908-454-4070
Mailing Address - Fax:
Practice Address - Street 1:600 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1971
Practice Address - Country:US
Practice Address - Phone:908-454-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ37PC00601200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7794703OtherAGENCY PROGRAM PROVIDER #
NJ0023701OtherAGENCY PROVIDER #