Individual
JOHNNA REVIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
5768 HIGHWAY 14, GRAY COURT, SC 29645-6764
(864) 872-2116
Mailing address
5768 HIGHWAY 14, GRAY COURT, SC 29645-6764
Taxonomy
Speciality
Code
Description
License number
State
320700000X
Physical Disabilities Residential Treatment Facility
Primary
1771
SC
Other
Enumeration date
08/12/2015
Last updated
08/12/2015
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