Provider Demographics
NPI:1710161484
Name:REVELES, ALYSSA CAMPBELL (MA, LPC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CAMPBELL
Last Name:REVELES
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 NW MT WASHINGTON DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1574
Mailing Address - Country:US
Mailing Address - Phone:541-350-9062
Mailing Address - Fax:
Practice Address - Street 1:745 NW MT WASHINGTON DR
Practice Address - Street 2:SUITE 302
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-1574
Practice Address - Country:US
Practice Address - Phone:541-350-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional