Provider Demographics
NPI:1811753031
Name:REVILLE, CHRISTINA NOEL
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:NOEL
Last Name:REVILLE
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 1:5191 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5639
Mailing Address - Country:US
Mailing Address - Phone:716-698-8064
Mailing Address - Fax:
Practice Address - Street 1:1041 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1042
Practice Address - Country:US
Practice Address - Phone:207-699-4111
Practice Address - Fax:207-773-8814
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6674225100000X
NY050990225100000X
NCP23275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist