Provider Demographics
NPI:1831501667
Name:REVELETTE, VICKIE (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:REVELETTE
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 HITESHUE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:OH
Mailing Address - Zip Code:45050-1567
Mailing Address - Country:US
Mailing Address - Phone:513-808-5668
Mailing Address - Fax:
Practice Address - Street 1:6840 LAKOTA LN
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-9578
Practice Address - Country:US
Practice Address - Phone:513-755-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.7479235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist