Provider Demographics
NPI:1396196846
Name:REVELS, KELLI (LCAS, CSI)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:REVELS
Suffix:
Gender:F
Credentials:LCAS, CSI
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CHASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCAS, CSI
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 OLD MARS HILL HWY STE 3
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28787
Practice Address - Country:US
Practice Address - Phone:828-645-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22735101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)