Healthcare Provider Details

I. General information

NPI: 1548771876
Provider Name (Legal Business Name): ALDO ENRIQUE REVILLA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALDO REVILLA PHD

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 W. PONDEROSA STREET
WHITERIVER AZ
85941
US

IV. Provider business mailing address

1170 N WOODLAND RD
LAKESIDE AZ
85929-7207
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-4811
  • Fax:
Mailing address:
  • Phone: 928-551-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5287
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: