Provider Demographics
NPI:1538174107
Name:REVERE, VIRGINIA L (PHD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:L
Last Name:REVERE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9012 LINTON LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22308-2733
Mailing Address - Country:US
Mailing Address - Phone:703-780-4872
Mailing Address - Fax:
Practice Address - Street 1:9012 LINTON LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22308-2733
Practice Address - Country:US
Practice Address - Phone:703-780-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000939101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7703431Medicaid
VA7703431Medicaid