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General NPI Number Information
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NPI Number | 1932559911
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Entity Type | Individual
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Provider Name | JONATHAN REVELS LCAS, CCS, NCC
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Gender | Male
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Dates
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Enumeration Date | 06/21/2016
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Last Update Date | 07/21/2025
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Provider Practice Location Address
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Address Line | 157 BROZZINI CT
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City | GREENVILLE
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State | SC
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Zip | 29615-5340
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Country | US
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Telephone | 800-809-6989
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Fax |
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Provider Business Mailing Address
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Address Line | 200 E BROAD ST STE 300
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City | GREENVILLE
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State | SC
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Zip | 29601-2891
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Country | US
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Telephone | 800-809-6989
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCAS-22868
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License Number State | NC
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