Provider Demographics
NPI:1245033158
Name:RAPHAEL REVELLA LICENSED CLINICAL SOCIAL WORK PLLC
Entity type:Organization
Organization Name:RAPHAEL REVELLA LICENSED CLINICAL SOCIAL WORK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:REVELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:518-630-8351
Mailing Address - Street 1:432 4TH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-3034
Mailing Address - Country:US
Mailing Address - Phone:518-630-8351
Mailing Address - Fax:
Practice Address - Street 1:432 4TH AVE APT 9
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-3034
Practice Address - Country:US
Practice Address - Phone:518-630-8351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health