Provider Demographics
NPI:1689325698
Name:AREVALO, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:AREVALO
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 1:14649 SATICOY ST APT 212
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-1256
Mailing Address - Country:US
Mailing Address - Phone:818-966-7827
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD STE 414
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5050
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 106S00000X
CA390200000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program