Provider Demographics
NPI:1255026423
Name:REVELS, RANDI PAIGE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:PAIGE
Last Name:REVELS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TUPELO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:FL
Mailing Address - Zip Code:32187-2468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 TUPELO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:FL
Practice Address - Zip Code:32187-2468
Practice Address - Country:US
Practice Address - Phone:386-916-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty