Healthcare Provider Details

I. General information

NPI: 1033237581
Provider Name (Legal Business Name): JULIE D REVILLE MS CCCSLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CHURCH ST SUITE 4G
BURLINGTON VT
05401-4299
US

IV. Provider business mailing address

2 CHURCH ST SUITE 4G
BURLINGTON VT
05401-4299
US

V. Phone/Fax

Practice location:
  • Phone: 802-734-0777
  • Fax:
Mailing address:
  • Phone: 802-734-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000747
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01038597
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: