Provider Demographics
NPI:1659320265
Name:REAVIS, MARY R (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:R
Last Name:REAVIS
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 1:518 S ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-2735
Mailing Address - Country:US
Mailing Address - Phone:704-530-0850
Mailing Address - Fax:704-735-9810
Practice Address - Street 1:518 S ASPEN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-2735
Practice Address - Country:US
Practice Address - Phone:704-530-0850
Practice Address - Fax:704-735-9810
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000865Medicaid
NC6000865Medicaid