Provider Demographics
NPI:1063097251
Name:REVELS, ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:REVELS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12823 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776-3626
Mailing Address - Country:US
Mailing Address - Phone:352-672-1741
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:12823 80TH AVE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-3626
Practice Address - Country:US
Practice Address - Phone:352-672-1741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29320225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant