Provider Demographics
NPI:1871780213
Name:REVUELTA, ALYSSA (PHD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:REVUELTA
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 1:10 RESOLUTE LN
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6608
Mailing Address - Country:US
Mailing Address - Phone:843-810-9682
Mailing Address - Fax:843-408-4478
Practice Address - Street 1:10 RESOLUTE LN
Practice Address - Street 2:SUITE 207
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6608
Practice Address - Country:US
Practice Address - Phone:843-810-9682
Practice Address - Fax:843-408-4478
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1184103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent