Provider Demographics
NPI:1528659570
Name:MINGO, REVA (LPC, LADC)
Entity type:Individual
Prefix:
First Name:REVA
Middle Name:
Last Name:MINGO
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ARROW RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1301
Mailing Address - Country:US
Mailing Address - Phone:959-245-4516
Mailing Address - Fax:
Practice Address - Street 1:61 ARROW RD STE 103
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1301
Practice Address - Country:US
Practice Address - Phone:959-245-4516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CT5554101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)