Provider Demographics
NPI:1215610084
Name:REVELL, TAYLOR LEWIS (OTR/L)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEWIS
Last Name:REVELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 ALDERMAN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLET
Mailing Address - State:GA
Mailing Address - Zip Code:30415-8234
Mailing Address - Country:US
Mailing Address - Phone:912-536-6838
Mailing Address - Fax:
Practice Address - Street 1:1357 ALDERMAN RD
Practice Address - Street 2:
Practice Address - City:BROOKLET
Practice Address - State:GA
Practice Address - Zip Code:30415-8234
Practice Address - Country:US
Practice Address - Phone:912-536-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008909225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist