Provider Demographics
NPI:1316110216
Name:REVILLE, LYNNETTE RENEE (MA, CCC-A)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:RENEE
Last Name:REVILLE
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S.APOLLO
Mailing Address - Street 2:DR BLENDA DICKENSON
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 SOUTH APOLLO
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-508-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY000498231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist