Provider Demographics
NPI:1235776071
Name:REVIVO, SIVAN
Entity Type:Individual
Prefix:
First Name:SIVAN
Middle Name:
Last Name:REVIVO
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 1:6300 BEEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3123
Mailing Address - Country:US
Mailing Address - Phone:818-572-7275
Mailing Address - Fax:
Practice Address - Street 1:19730 VENTURA BLVD STE 103B
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2693
Practice Address - Country:US
Practice Address - Phone:818-884-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27586235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist