Provider Demographics
NPI:1275963670
Name:REVELS LEE, TIFANI MEGAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TIFANI
Middle Name:MEGAN
Last Name:REVELS LEE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 HALSEY AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-2654
Mailing Address - Country:US
Mailing Address - Phone:239-481-8855
Mailing Address - Fax:
Practice Address - Street 1:6202 PRESIDENTIAL CT
Practice Address - Street 2:SUITE B
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3563
Practice Address - Country:US
Practice Address - Phone:239-481-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA74492225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist