Healthcare Provider Details

I. General information

NPI: 1619021235
Provider Name (Legal Business Name): MRS. ADA ISABEL REVELES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD SUITE #245
BUENA PARK CA
90621-2840
US

IV. Provider business mailing address

6301 BEACH BLVD SUITE #245
BUENA PARK CA
90621-2840
US

V. Phone/Fax

Practice location:
  • Phone: 714-736-0231
  • Fax: 714-736-0895
Mailing address:
  • Phone: 714-736-0231
  • Fax: 714-736-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: