MEDICARE: DR. ELAINE SUSAN REVIS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6207	OH

General Provider Information

NPI Number	:	1033124912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELAINE SUSAN REVIS PH.D.

Provider Business Mailing Address
First Line	:	23811 CHAGRIN BLVD STE 310
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5525
Country	:	US
Telephone Number	:	216-464-1277
Fax Number	:

Provider Business Practice Location Address
First Line	:	23811 CHAGRIN BLVD STE 310
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5525
Country	:	US
Telephone Number	:	216-464-1277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/08/2007

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