Healthcare Provider Details

I. General information

NPI: 1972847945
Provider Name (Legal Business Name): MARICON REVIS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 TAFT BLVD STE 2
WICHITA FALLS TX
76308-4800
US

IV. Provider business mailing address

95-1001 KOOLANI DR APT F601
MILILANI HI
96789-6021
US

V. Phone/Fax

Practice location:
  • Phone: 940-691-1899
  • Fax: 940-691-3423
Mailing address:
  • Phone: 808-286-9115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number81717
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: