Provider Demographics
NPI:1295863355
Name:REVELES, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:920 E SAN ANTONIO DR APT 2
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2220
Mailing Address - Country:US
Mailing Address - Phone:916-412-5607
Mailing Address - Fax:
Practice Address - Street 1:3711 LONG BEACH BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3319
Practice Address - Country:US
Practice Address - Phone:562-216-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator