Healthcare Provider Details

I. General information

NPI: 1710339031
Provider Name (Legal Business Name): MRS. REBECCA REVELS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 FELICIA AVE
TALLULAH LA
71282
US

IV. Provider business mailing address

1705 FELICIA AVE
TALLULAH LA
71282-8203
US

V. Phone/Fax

Practice location:
  • Phone: 318-574-1232
  • Fax: 318-574-8646
Mailing address:
  • Phone: 318-574-1232
  • Fax: 318-574-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9497
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: