Basic Information
| Provider Information | |||||||||
| NPI: | 1932559911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVELS | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MS, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 CLANTON RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171309 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 W MEDICAL CT | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287525590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286593966 | ||||||||
| FaxNumber: | 8286596304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-22868 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.