Provider Demographics
NPI:1518219096
Name:REVELS, SANTOSHA MICHELLE
Entity Type:Individual
Prefix:
First Name:SANTOSHA
Middle Name:MICHELLE
Last Name:REVELS
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 1:5316 SUMMER TROUT ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-6616
Mailing Address - Country:US
Mailing Address - Phone:702-591-3029
Mailing Address - Fax:702-649-2643
Practice Address - Street 1:5316 SUMMER TROUT ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-6616
Practice Address - Country:US
Practice Address - Phone:702-591-3029
Practice Address - Fax:702-649-2643
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst