Healthcare Provider Details

I. General information

NPI: 1184208506
Provider Name (Legal Business Name): CHARLENE REVELES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18623 GALE AVE STE 154
CITY OF INDUSTRY CA
91748-1342
US

IV. Provider business mailing address

18623 GALE AVE STE 154
CITY OF INDUSTRY CA
91748-1342
US

V. Phone/Fax

Practice location:
  • Phone: 626-839-0300
  • Fax:
Mailing address:
  • Phone: 626-839-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT143722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: