Provider Demographics
NPI:1548771876
Name:REVILLA, ALDO ENRIQUE
Entity Type:Individual
Prefix:
First Name:ALDO
Middle Name:ENRIQUE
Last Name:REVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALDO
Other - Middle Name:
Other - Last Name:REVILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:BERMISS RD, MOODY AFB
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31699
Mailing Address - Country:US
Mailing Address - Phone:229-257-4211
Mailing Address - Fax:
Practice Address - Street 1:BERMISS RD, MOODY AFB
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31699
Practice Address - Country:US
Practice Address - Phone:229-257-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4858103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist