Provider Demographics
NPI:1568887537
Name:DIAZ REVELO, GUSTAVO NICOLAS
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:NICOLAS
Last Name:DIAZ REVELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 DUMBARTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1533
Mailing Address - Country:US
Mailing Address - Phone:443-791-8384
Mailing Address - Fax:
Practice Address - Street 1:100 OWINGS CT
Practice Address - Street 2:SUITE 8
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-6428
Practice Address - Country:US
Practice Address - Phone:410-526-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)