MEDICARE: VICKIE REVELETTE M.S, CCC/SLP

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	235Z00000X	Speech-Language Pathologist	SP.7479	OH

General Provider Information

NPI Number	:	1831501667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE REVELETTE M.S, CCC/SLP

Provider Business Mailing Address
First Line	:	670 HITESHUE AVE
Second Line	:
City	:	MONROE
State	:	OH
Zip	:	45050-1567
Country	:	US
Telephone Number	:	513-808-5668
Fax Number	:

Provider Business Practice Location Address
First Line	:	6840 LAKOTA LN
Second Line	:
City	:	LIBERTY TOWNSHIP
State	:	OH
Zip	:	45044-9578
Country	:	US
Telephone Number	:	513-755-7211
Fax Number	:

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

Provider Enumeration Date	:	05/28/2014
Last Update Date	:	05/28/2014

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Directions to “ VICKIE REVELETTE M.S, CCC/SLP” Practice Location

Language	Start Address	Practice Location

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