Healthcare Provider Details

I. General information

NPI: 1326896879
Provider Name (Legal Business Name): REVITAL CARROLL DOULA, CMT, CEIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 VAN NESS AVE
SANTA CRUZ CA
95060-3538
US

IV. Provider business mailing address

326 VAN NESS AVE
SANTA CRUZ CA
95060-3538
US

V. Phone/Fax

Practice location:
  • Phone: 928-713-7123
  • Fax:
Mailing address:
  • Phone: 928-713-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: