Basic Information
| Provider Information | |||||||||
| NPI: | 1174174601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVIS | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REVIS | ||||||||
| OtherFirstName: | JOEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 311 GENERAL GRIFFITH CIR | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281399273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284298620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 356 CHARLOTTE RD | ||||||||
| Address2: | |||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281392916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282877945 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2019 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C006046 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.