Provider Demographics
NPI:1801023023
Name:REVELS, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:REVELS
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 1:312 BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-9716
Mailing Address - Country:US
Mailing Address - Phone:580-222-1528
Mailing Address - Fax:
Practice Address - Street 1:312 BARBARA ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-9716
Practice Address - Country:US
Practice Address - Phone:580-222-1528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)