Basic Information
| Provider Information | |||||||||
| NPI: | 1417167958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVELL | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | HOFFMAN | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 168 TIMBER RIDGE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764501443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405491814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1325 1ST ST | ||||||||
| Address2: | |||||||||
| City: | GRAHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764503603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405498787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 09/20/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1148497 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2482 | OK | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.