Provider Demographics
NPI:1568633774
Name:PARKER, REVA
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 FAIRWAY DR
Mailing Address - Street 2:#208
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 FAIRWAY DR
Practice Address - Street 2:#208
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5871
Practice Address - Country:US
Practice Address - Phone:406-586-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC#365106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist