Provider Demographics
NPI:1083314090
Name:REVELES, CHRISTINA ELIZABETH
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ELIZABETH
Last Name:REVELES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10261 TRADEMARK ST.
Mailing Address - Street 2:SUITE C
Mailing Address - City:RANCHO
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:909-317-8499
Mailing Address - Fax:
Practice Address - Street 1:10261 TRADEMARK ST.
Practice Address - Street 2:SUITE C
Practice Address - City:RANCHO
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:909-317-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician