Provider Demographics
NPI:1699409482
Name:REVILLA, SHELLIE LEE
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:LEE
Last Name:REVILLA
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 1:4916 POPLAR TER
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-5717
Mailing Address - Country:US
Mailing Address - Phone:408-202-3992
Mailing Address - Fax:
Practice Address - Street 1:4916 POPLAR TER
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-5717
Practice Address - Country:US
Practice Address - Phone:408-202-3992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT35689106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty