1750935110 NPI number — MR. HUMBERTO XAVIER REVELES MSW, LCSW

Table of content: MR. HUMBERTO XAVIER REVELES MSW, LCSW (NPI 1750935110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750935110 NPI number — MR. HUMBERTO XAVIER REVELES MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVELES
Provider First Name:
HUMBERTO
Provider Middle Name:
XAVIER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REVELES
Provider Other First Name:
H.
Provider Other Middle Name:
XAVIER
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750935110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 HEWITT DR STE 103, #218
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76712-6693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-686-6012
Provider Business Mailing Address Fax Number:
512-842-7227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 OWEN LANE SUITE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-686-6012
Provider Business Practice Location Address Fax Number:
512-842-7227
Provider Enumeration Date:
07/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  63430 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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