Healthcare Provider Details

I. General information

NPI: 1003794736
Provider Name (Legal Business Name): CARLO REVELES RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18521 E QUEEN CREEK RD STE 105-627
QUEEN CREEK AZ
85142-5866
US

IV. Provider business mailing address

18521 E QUEEN CREEK RD STE 105-627
QUEEN CREEK AZ
85142-5866
US

V. Phone/Fax

Practice location:
  • Phone: 480-361-1025
  • Fax: 480-814-7488
Mailing address:
  • Phone: 480-361-1025
  • Fax: 480-814-7488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-464569
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: