Provider Demographics
NPI:1841480696
Name:REVAK, SUSAN ANN (PCC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:REVAK
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-2805
Mailing Address - Country:US
Mailing Address - Phone:330-929-9754
Mailing Address - Fax:
Practice Address - Street 1:155 N WATER ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2418
Practice Address - Country:US
Practice Address - Phone:330-678-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0008416.101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health