Provider Demographics
NPI:1437612801
Name:ROBINSON, REVA MATTHIEW (MBA)
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:MATTHIEW
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:REVA
Other - Middle Name:LATISHA
Other - Last Name:MATTHIEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5454
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5454
Mailing Address - Country:US
Mailing Address - Phone:318-218-5543
Mailing Address - Fax:318-625-0638
Practice Address - Street 1:505 E TRAVIS ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-4258
Practice Address - Country:US
Practice Address - Phone:281-223-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid