Provider Demographics
NPI:1457916264
Name:REVILL, HEATHER E
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:REVILL
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 1:98 FAIR DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-5926
Mailing Address - Country:US
Mailing Address - Phone:860-990-1346
Mailing Address - Fax:
Practice Address - Street 1:98 FAIR DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02726-5926
Practice Address - Country:US
Practice Address - Phone:860-990-1346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002927101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional