MEDICARE: IMELDA RAMIREZ REVERON MA, CLINICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1144893694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMELDA RAMIREZ REVERON MA, CLINICIAN

Provider Business Mailing Address
First Line	:	21916 PARK VIEW DR
Second Line	:
City	:	GARDEN RIDGE
State	:	TX
Zip	:	78266-2749
Country	:	US
Telephone Number	:	210-844-9985
Fax Number	:	210-600-3849

Provider Business Practice Location Address
First Line	:	4335 W PIEDRAS DR STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-1215
Country	:	US
Telephone Number	:	210-600-4117
Fax Number	:	210-600-3849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2021
Last Update Date	:	07/22/2021

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