Provider Demographics
NPI:1033572086
Name:REVILLA, NATASHA (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:REVILLA
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4351
Mailing Address - Country:US
Mailing Address - Phone:951-390-7575
Mailing Address - Fax:
Practice Address - Street 1:132 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543
Practice Address - Country:US
Practice Address - Phone:951-390-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT91215106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist