Healthcare Provider Details

I. General information

NPI: 1750237806
Provider Name (Legal Business Name): REAVIVO MARRIAGE AND FAMILY THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 HOLIDAY CT STE 201
LA JOLLA CA
92037-1808
US

IV. Provider business mailing address

6059 DEERFORD ROW
LA JOLLA CA
92037-0904
US

V. Phone/Fax

Practice location:
  • Phone: 858-209-4270
  • Fax:
Mailing address:
  • Phone: 858-209-4270
  • Fax:

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: ALONDRA HERNANDEZ
Title or Position: OWNER
Credential: LMFT
Phone: 858-209-4270