Provider Demographics
NPI:1518277433
Name:REVILLA, MARIA ELISABET (PHD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELISABET
Last Name:REVILLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94041-2030
Mailing Address - Country:US
Mailing Address - Phone:650-965-2020
Mailing Address - Fax:650-965-7286
Practice Address - Street 1:1350 W ROBINHOOD DR STE 18
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5519
Practice Address - Country:US
Practice Address - Phone:650-279-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23560103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist