Provider Demographics
NPI:1063246502
Name:REVELS, BILLIE JO
Entity type:Individual
Prefix:
First Name:BILLIE
Middle Name:JO
Last Name:REVELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CONFEDERATE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-8552
Mailing Address - Country:US
Mailing Address - Phone:386-937-0173
Mailing Address - Fax:
Practice Address - Street 1:100 N LAKE ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2620
Practice Address - Country:US
Practice Address - Phone:386-937-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist