Provider Demographics
NPI:1487748281
Name:REVILL, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:REVILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 FAYETTEVILLE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6254
Mailing Address - Country:US
Mailing Address - Phone:919-572-0001
Mailing Address - Fax:919-572-0004
Practice Address - Street 1:300 W TRYON ST
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2438
Practice Address - Country:US
Practice Address - Phone:919-732-1150
Practice Address - Fax:919-732-1179
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional