MEDICARE: REVELATION THERAPY SERVICES

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	174400000X	Specialist

General Provider Information

NPI Number	:	1780676999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVELATION THERAPY SERVICES

Provider Business Mailing Address
First Line	:	840 S 13TH ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07108-1316
Country	:	US
Telephone Number	:	862-452-6086
Fax Number	:	973-374-4494

Provider Business Practice Location Address
First Line	:	840 S 13TH ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07108-1316
Country	:	US
Telephone Number	:	862-452-6086
Fax Number	:	973-374-4494

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. TIBISAY NISBETT
Credential	:	PT
Telephone Number	:	862-452-6086

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	08/22/2020

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Directions to “REVELATION THERAPY SERVICES ” Practice Location

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