Provider Demographics
NPI:1154453843
Name:REVETTO, JOSEPH P (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:REVETTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 W COLTON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2861
Mailing Address - Country:US
Mailing Address - Phone:909-556-3939
Mailing Address - Fax:
Practice Address - Street 1:1255 W COLTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2861
Practice Address - Country:US
Practice Address - Phone:909-556-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL160330Medicare ID - Type Unspecified