Provider Demographics
NPI:1932205143
Name:REVOAL, WALTER DAVID (MA, LPC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:DAVID
Last Name:REVOAL
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3757 STUART ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1921
Mailing Address - Country:US
Mailing Address - Phone:303-455-3288
Mailing Address - Fax:
Practice Address - Street 1:834 S SHERMAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6323
Practice Address - Country:US
Practice Address - Phone:303-776-7840
Practice Address - Fax:303-776-7161
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2103101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor