Healthcare Provider Details

I. General information

NPI: 1114730868
Provider Name (Legal Business Name): REVATHI NAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 661448
BRONX NY
10466-0242
US

IV. Provider business mailing address

PO BOX 661448
BRONX NY
10466-0242
US

V. Phone/Fax

Practice location:
  • Phone: 718-644-1742
  • Fax:
Mailing address:
  • Phone: 718-644-1742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCASAC-T-41090
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: