Provider Demographics
NPI:1700057825
Name:REVERCOMB, ANGELA L
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:REVERCOMB
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 1:7901 ANOKA RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-3305
Mailing Address - Country:US
Mailing Address - Phone:804-229-3172
Mailing Address - Fax:
Practice Address - Street 1:3111 NORTHSIDE AVE STE 375
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-5441
Practice Address - Country:US
Practice Address - Phone:804-229-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
071003714101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104858653Medicaid