Provider Demographics
NPI:1841748860
Name:REVANS-MCMENIMON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:REVANS-MCMENIMON
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 1:70 BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-1610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-1610
Practice Address - Country:US
Practice Address - Phone:914-769-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003414101YM0800X
NY000615106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist