Provider Demographics
NPI:1063086338
Name:REVERON, ROSARIO (LAC)
Entity type:Individual
Prefix:MS
First Name:ROSARIO
Middle Name:
Last Name:REVERON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 EDGEMONT CRES
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6604
Mailing Address - Country:US
Mailing Address - Phone:973-437-6288
Mailing Address - Fax:
Practice Address - Street 1:7 GLENWOOD AVE STE 101
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1041
Practice Address - Country:US
Practice Address - Phone:973-675-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00507900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health