Healthcare Provider Details

I. General information

NPI: 1932559911
Provider Name (Legal Business Name): JONATHAN REVELS MS, LCDP, LPCMH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 MATTLIND WAY
MILFORD DE
19963-5369
US

IV. Provider business mailing address

1011 MATTLIND WAY
MILFORD DE
19963-5369
US

V. Phone/Fax

Practice location:
  • Phone: 302-725-5411
  • Fax:
Mailing address:
  • Phone: 302-725-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC-0012132
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20684
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-22868
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19082010
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCD-0010182
License Number StateDE
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12286
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: