Provider Demographics
NPI:1407467673
Name:REVAK, MARIA (AUD-CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:REVAK
Suffix:
Gender:F
Credentials:AUD-CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 WELLES ST
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4968
Mailing Address - Country:US
Mailing Address - Phone:570-283-0524
Mailing Address - Fax:570-283-0302
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-283-0524
Practice Address - Fax:570-283-0302
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006089237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter