Provider Demographics
NPI:1891253613
Name:REVELES, ADRIAN (MSW CLINICIAN)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:REVELES
Suffix:
Gender:M
Credentials:MSW CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7554 WELLMAN ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-3314
Mailing Address - Country:US
Mailing Address - Phone:323-868-1281
Mailing Address - Fax:
Practice Address - Street 1:505 S PACIFIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2656
Practice Address - Country:US
Practice Address - Phone:310-774-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
CA1127181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical