MEDICARE: MS. KATHRYN MARY REVETTA

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1225293327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHRYN MARY REVETTA

Provider Business Mailing Address
First Line	:	2604 RHONDA DR
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-6544
Country	:	US
Telephone Number	:	417-256-0418
Fax Number	:

Provider Business Practice Location Address
First Line	:	2604 RHONDA DR
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-6544
Country	:	US
Telephone Number	:	417-256-0418
Fax Number	:

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

Provider Enumeration Date	:	07/28/2008
Last Update Date	:	07/28/2008

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