Provider Demographics
NPI:1972847945
Name:REVIS, MARICON (LMHC)
Entity Type:Individual
Prefix:MISS
First Name:MARICON
Middle Name:
Last Name:REVIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1001 KOOLANI DR APT F601
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-6021
Mailing Address - Country:US
Mailing Address - Phone:808-286-9115
Mailing Address - Fax:
Practice Address - Street 1:4722 TAFT BLVD STE 2
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4800
Practice Address - Country:US
Practice Address - Phone:940-691-1899
Practice Address - Fax:940-691-3423
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TX81717101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker