Provider Demographics
NPI:1750081303
Name:REVILLA, CHASITY FAITH
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:FAITH
Last Name:REVILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHASITY
Other - Middle Name:FAITH
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:592 BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3522
Mailing Address - Country:US
Mailing Address - Phone:865-279-2919
Mailing Address - Fax:
Practice Address - Street 1:2300 PAVILION DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4622
Practice Address - Country:US
Practice Address - Phone:423-765-9655
Practice Address - Fax:423-392-4795
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002686224Z00000X
TN3806224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant