Healthcare Provider Details

I. General information

NPI: 1285565416
Provider Name (Legal Business Name): LIBBY BURR REVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIBBY ELEANOR BURR

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 BETHEL ST APT 2
NORWALK CT
06855-1953
US

IV. Provider business mailing address

7 BETHEL ST APT 2
NORWALK CT
06855-1953
US

V. Phone/Fax

Practice location:
  • Phone: 203-554-6281
  • Fax:
Mailing address:
  • Phone: 203-554-6281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1061
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: