Provider Demographics
NPI:1609695535
Name:REVELO, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:REVELO
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 1:4001 PRINCE WILLIAM PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 PRINCE WILLIAM PKWY STE 301
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7667
Practice Address - Country:US
Practice Address - Phone:703-688-8541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker