Provider Demographics
NPI:1740410711
Name:ROSELIUS, REVA JO (LPC)
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:JO
Last Name:ROSELIUS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5884
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79117-5884
Mailing Address - Country:US
Mailing Address - Phone:806-351-7200
Mailing Address - Fax:
Practice Address - Street 1:1411 AMARILLO BLVDE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-5555
Practice Address - Country:US
Practice Address - Phone:806-351-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14002103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist