Provider Demographics
NPI:1548800931
Name:REVEKANT, LEXIE L (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LEXIE
Middle Name:L
Last Name:REVEKANT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LEXIE
Other - Middle Name:L
Other - Last Name:MOMBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 420721
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92142-0721
Mailing Address - Country:US
Mailing Address - Phone:716-224-0963
Mailing Address - Fax:
Practice Address - Street 1:2751 ROOSEVELT RD STE 203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6180
Practice Address - Country:US
Practice Address - Phone:619-501-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT33880225100000X
TX1332541225100000X
CA301017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist