Healthcare Provider Details

I. General information

NPI: 1235737222
Provider Name (Legal Business Name): RAPHAEL ANGELA REVELLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 ELMHURST AVE
COLONIE NY
12205-5416
US

IV. Provider business mailing address

36 ELMHURST AVE
COLONIE NY
12205-5416
US

V. Phone/Fax

Practice location:
  • Phone: 518-328-4244
  • Fax: 845-579-8090
Mailing address:
  • Phone: 518-630-8351
  • Fax: 845-579-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number099081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: