Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1013236645 |
---|---|
Provider Name | Jill Revere |
First Address | Merrillville, IN 46410-6307 |
Second Address | Merrillville, IN 46410-6307 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2010 |
Last Update Date | 25/06/2021 |