Provider Demographics
NPI:1720699135
Name:GREENUP, REVA M
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:M
Last Name:GREENUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REVA
Other - Middle Name:M
Other - Last Name:NEWCOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-9120
Mailing Address - Country:US
Mailing Address - Phone:702-218-7715
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:702-218-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician