Healthcare Provider Details

I. General information

NPI: 1245033158
Provider Name (Legal Business Name): RAPHAEL REVELLA LICENSED CLINICAL SOCIAL WORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2025
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: 518-630-8351
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. RAPHAEL ANGELA REVELLA
Title or Position: OWNER/MANAGER
Credential: LCSW
Phone: 518-630-8351